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The consent covers multiple media types and purposes such as education, marketing/advertising, and internal medical records, and allows use across present and future platforms. Signing confirms voluntary participation, no compensation, waiver of final product approval, liability release, and understanding of revocation limits after use.",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/photo-and-video-consent-and-release-form-patientguardian-signature-jan-2026/307365/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/photo-and-video-consent-and-release-form-patientguardian-signature-jan-2026/307365.png","ImageObject",442,249,{"name":88,"@type":89},"McQueen","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"Who must complete the form, and what role does the legal guardian have?","Question",{"text":109,"@type":110},"The patient (or legal guardian if the patient is a minor) completes the form. If the patient is a minor, a parent or legal guardian must sign the minor section and confirm authority to sign.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What types of media and patient information are covered by consent?",{"text":114,"@type":110},"Consent covers still photographs, video recordings, audio recordings, and quotes/testimonials, including Protected Health Information (PHI) such as before/after images and treatment details as indicated in the scope.",{"name":116,"@type":107,"acceptedAnswer":117},"What purposes and platforms may the healthcare practice use the media for?",{"text":118,"@type":110},"The practice may use the media for educational purposes, marketing/advertising, and internal medical records only. 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Healthcare is not affected by the decision, and the authorization can be revoked in writing, though not for media already in use.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},307365,1790468859,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":144,"read_time":9},5909890329169,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","PHOTO/VIDEO RELEASE FORM  \nPatient Photo and Video Release Form Template  \n[NAME OF HEALTHCARE PRACTICE/ORGANIZATION]  \nPHOTO AND VIDEO CONSENT AND RELEASE FORM  \nI. Parties Involved  \n• Patient/Releasor:  \no Printed Name:    \no Date of Birth:    \no Address:    \no Phone:   Email:    \n• Healthcare Practice/Releasee:  \no Name: [Name of Practice/Organization]  \no Address: [Address]  \nII. Consent and Scope of Release  \nI, the Patient named above (or legal guardian if the patient is a minor), hereby grant and authorize the Healthcare Practice, and its agents, assignees, and clients (\"Grantees\"), the irrevocable right to capture, use, edit, alter, copy, exhibit, publish, distribute, and make use of my image, likeness, voice, and/or Protected Health Information (PHI) as described below.  \n• Media Types Covered (initial all that apply):  \no   Still photographs  \no   Video recordings  \no   Audio recordings  \no   Quotes/written testimonials  \no   My Protected Health Information (PHI), which may include before/after images, treatment details, etc.  \n• Purpose and Use (initial all intended uses): I authorize the use of the media for:  \no   Educational purposes (e.g., medical teaching, training, research presentations)  \no   Marketing and advertising (e.g., website, social media, print materials, email marketing, brochures)  \no   Internal medical records only (images used solely within my confidential medical chart)  \n• Platforms (where the media may appear):  \nThe media may be used by the practice and its affiliates in any format and on any platform, including websites, social media, digital ads, print materials, educational or internal use, and anyother current or future media.  \nIII. Terms and Waivers  \nBy signing this form, I confirm my voluntary participation and understand that no compensation will be provided for the use of the media. I waive the right to approve the final product and release the Healthcare Practice and its agents from liability for claims such as invasion of privacy or defamation. I also acknowledge that my healthcare will not be affected by my decision to sign or not sign this release and that I can revoke this authorization in writing, though not for media already in use.  \nIV. Patient/Guardian Signature  \nI am over 18 and understand the terms of this release.  \nSignature of Patient or Legal Guardian  \nDate  \n\n| If the patient is a minor, a parent or legal guardian must complete the following section. I am the parent or legal guardian and have the authority to sign for the minor. I am over 18. |\n| --- |\n| Signature of Parent/Legal Guardian |\n\nDate","cbCaijWS0B1QQoVl","https://ap.wps.com/l/cbCaijWS0B1QQoVl","pdf",64113,"English","# Parties Involved\n## Consent and Scope of Release\n# Terms and Waivers\n## Patient/Guardian Signature","[{\"question\":\"Who must complete the form, and what role does the legal guardian have?\",\"answer\":\"The patient (or legal guardian if the patient is a minor) completes the form. If the patient is a minor, a parent or legal guardian must sign the minor section and confirm authority to sign.\"},{\"question\":\"What types of media and patient information are covered by consent?\",\"answer\":\"Consent covers still photographs, video recordings, audio recordings, and quotes/testimonials, including Protected Health Information (PHI) such as before/after images and treatment details as indicated in the scope.\"},{\"question\":\"What purposes and platforms may the healthcare practice use the media for?\",\"answer\":\"The practice may use the media for educational purposes, marketing/advertising, and internal medical records only. The form allows use on any platform, including websites, social media, digital ads, and print materials, now or in the future.\"},{\"question\":\"What are the terms after signing, including compensation and liability?\",\"answer\":\"Signing confirms voluntary participation with no compensation, waives the right to approve the final product, and releases the practice and its agents from liability for claims such as invasion of privacy or defamation. Healthcare is not affected by the decision, and the authorization can be revoked in writing, though not for media already in use.\"}]","Photo and Video Consent and Release Form - Patient/Guardian Signature - Jan 2026 | PDF",1789848403]