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Photograph release form

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Patient Photographic and Videographic Consent Form

The patient’s photographs, videos, and other images may be used in medical journals, websites, or other educational materials to inform professionals about diagnosis and treatment of diseases or trauma related problems. Details such as age, sex, and treatment outcomes may be shared, but names and identifiable features will be kept confidential to protect the patient’s privacy, unless consent specifically includes the right to publish identifiable information for scientific and educational purposes.

This consent includes the right to reproduce and distribute the material in both printed form (e.g., journal contributions, medical textbooks) and digital media (e.g., educational films, electronic databases, social media platforms like Facebook, LinkedIn, Instagram, YouTube, and cloud-based services).

I understand that agreeing to this form does not affect the patient’s current or future medical care. The consent is freely given and is not conditional upon receiving any benefits; refusal will not have any influence to the further treatment of the patient.

I understand that photographs, videos, and other images have been taken during the patient’s treatment. I agree that these images may be used by the treating physician and other medical professionals for medical diagnosis, treatment, and education, including publications by various publishers.


Name: Date:   Signature:


(A legal representative must sign on behalf of patients under 18 or patients who are incapable of giving their consent or not present.)

Name: Relationship to Patient:
Date:   Signature:

I hereby transfer the copyright of the images to the treating physician and the hospital.

Physician Name: Hospital:  
  • SCImago Journal & Country Rank
  • Endoscopic slide-in orbital wall reconstruction for isolated medial blowout fractures. Arch Craniofac Surg. 2020;21:345-350


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Dept. of Plastic and Reconstructive Surgery Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
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