Vascular Surgery Photography and Video Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record Number: __________ Date: _________________________

Purpose of Documentation

I understand that photographs, videos, and/or digital images will be taken of my vascular condition, surgical procedure(s), and/or treatment for the following purposes:

• Clinical documentation and medical record keeping
• Surgical planning and treatment monitoring
• Quality assurance and peer review
• Medical education and training
• Scientific publication and presentations

Authorization

By signing this form, I authorize Dr. _________________ and [Practice Name] to:

1. Capture and store images/videos of my condition and treatment
2. Use these materials for the purposes listed above
3. Share these materials with:
   • Other healthcare providers involved in my care
   • Medical students and residents for educational purposes
   • Medical journals and conferences (with all identifying information removed)

Understanding and Rights

• I understand that my identity will be protected in any public use of these materials
• I may revoke this authorization in writing at any time
• Refusing to sign will not affect my right to treatment
• This authorization expires in 10 years unless otherwise specified

Signatures

Patient Signature: _________________ Date: _________________

Witness Signature: _________________ Date: _________________

Physician Signature: _______________ Date: _________________

Revocation

I hereby revoke this authorization (patient signature): _________________ Date of revocation: _________________