Authorization to Release Photographs


Patient’s name: _____________________________________ Date of birth: _________

 SSN: _______________________ Previous name: _____________________________

 Doctor’s Name __________________________________________________________

 Practice Name: __________________________________________________________


I authorize the above listed doctor and practice to release any and all photographs taken of the patient named above for the following uses:


            ___ Educational Journals

             ___ Teaching purposes

             ___ Website

             ___ Other _________________________________________________________

This request and authorization applies to photographs taken for the following treatment, condition, or dates of treatment:



THIS AUTHORIZATION EXPIRES ON                                           or _________ DAYS AFTER




I may cancel this authorization to the extent allowed by law.  If I do, I understand that the doctor or practice may have already released information about me after I gave permission.  I know that canceling this authorization would not prohibit any release of photographs by the doctor or practice in reliance on my original authorization.


To cancel this agreement, I must:

  •  Write a letter to the doctor or practice advising of my wish to cancel my authorization to disclose photographs taken of me by this practice.  I (or my authorized representative) must sign and date the letter.
  •  Once my doctor gives out any photographs I have approved, I know that my doctor has no control over them.  Federal or state privacy laws may no longer protect the information.


Signature of patient or patient’s authorized representative                            Date signed


Relationship or status if signed by parent, legal guardian, personal representative, etc.