PHOTO & VIDEO CONSENT FORM

1. Patient Information

Participant's Full Name *

Participant's Date of Birth *

Address

Parent/Guardian's Name (if applicable)

Email *

2. Level of Consent

Please review the options below and indicate your level of consent for the use of photographs and/or audiovisual recordings. You may choose more than one option. *

Internal Use Only. Within the organization, including educational and promotional materials distributed internally, internal presentations, or staff training.

Public Use. On external platforms, including the organisation's website, social media, and printed promotional materials.

No Social Media. Allow public use (e.g., website, brochures) but NOT on social media platforms.

Rights to use the individual’s likeness *

Face Usage Permission. I consent to use of images/recordings where my (or my child's) full face is visible.

Face Covered Use. I consent to use of images/recordings where my (or my child's) face is partially or fully covered (e.g., blurred or cropped).

Optional notes / permitted contexts

3. Duration of Use

I consent to the use of these images and recordings for the duration selected above. If "Indefinite" is selected, consent remains until withdrawn in writing.

Indefinite / until withdrawn

Until a specific date

Specific period

Please enter your preferred time here if applicable.

4. Rights & Ownership

I acknowledge I will not receive compensation and waive any rights to inspect/approve the finished materials or their use.

5. Privacy & Confidentiality

KT Beauty Medical Centre will not use images/recordings in a way that is defamatory, misleading, or violates my privacy.

6. Withdrawal of Consent

I understand consent can be withdrawn anytime by written notice to KT Beauty Medical Centre. Materials already published or distributed before withdrawal may still be used.

7. Signatures

Date *

Participant's Signature *

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Date

Parent/Guardian Signature (if applicable)

Clear

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