Consent for Photography

Organization Name: ACUHEAL WOUND SPECIALISTS

In connection with the medical care I am receiving through this institution, I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that ACUHEAL WOUND SPECIALISTS will retain the ownership rights to these photographs, videotapes, digital images, or other images but that I will be allowed to view them or obtain copies.

I, certify that the information provided is true and accurate to the best of my knowledge. I understand that providing false information may result in the rejection of my application.

, consent that still, or digital photographs be taken of wounded areas on my body under the following conditions:

• The photographs are taken for the express purpose of participation in a case study or for education purposes, and at no time will my name or any other identifying material be connected to these photographs that could be construed as a violation of my privacy.

• The photographs will be taken for the express purpose of documenting my care, and at no time will my name or any other identifying material be connected to these photographs that could be construed as a violation of my privacy.

Wounded areas to be photographed include:

1) is required.
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 I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the period required by law or outlined in ACUHEAL WOUND SPECIALISTS’s policy.

The photographs will be taken by a member of the nursing staff, wound care team, or by a designated photographer as authorized by ACUHEAL WOUND SPECIALISTS. I accept no compensation or other remuneration for using such photographs as I have authorized.

Patient Name (Parent/guardian must obtain consent if the subject is a minor.)

Name is required.
Please provide a valid date.
Authorized Name is required.
Please provide a valid date.
Relationship to Patient is required.
Reason Patient Cannot Sign is required.

Witness

Name is required.
Please provide a valid date.

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