Patient Photograph, Video or Audio Recording Release Form

5 Minutes to complete

The Karri Clinic is committed to educating the public about medical treatments and healthcare. One way we do that is through patient images or stories that are shared through the media or The Karri Clinic’s own publications and web site.

By signing this form, you are authorising us to share photographs, video or audio recording about you as part of these efforts.

I understand that:

1. Photographs, video, and/or audio recordings may be taken of me or parts of my body before, during, and after surgery

2. My identity will never be revealed unless I give explicit consent.

3. My photographs, video, and/or audio recordings will be shared with the public, doctors or health professionals through the following media: medical publications, medical journals, medical textbooks, The Karri Clinic’s literature, web site, social media platforms (i.e., Instagram, Facebook, Twitter) and commercial media such as newspapers and television for marketing and/or educational purposes.

4. Refusal to consent to photographs, video, and/or audio recording will in no way affect the medical care I will receive.

5. Although photographs, video, and/or audio recordings will be used without identifying information, I understand it is possible someone may recognize me.

6. I may request a copy of, or access to, these photographs, video, and/or audio recordings. The Karri Clinic’s reserves the right to edit such photographs, video, and/or audio recording, to preserve privacy of staff, other patients or protect commercially sensitive information and I will only have access to such edited versions.

7. All photographs, video, and/or audio recordings remain the property of The Karri Clinic and are held in accordance with the Data Protection Act 1998.

8. My participation is voluntary and agree that use of any photographs, video, and/or audio recording confers no rights of ownership or royalties whatsoever.

9. My participation is completely voluntary, and I can withdraw my consent, in writing to The Karri Clinic, at any time in the future.

10. Withdrawal of my consent will come into effect from the date the withdrawal is received by The Karri Clinic and photographs, video, and/or audio recordings that are already in the public domain up to that point cannot be withdrawn.

11. Once the photographs, video or audio recordings are shared through publications, web sites, social media and/or commercial media, The Karri Clinic cannot control its further dissemination.

12. I hereby release The Karri Clinic, its employees, and any third parties involved in the creation of or publication of educational or marketing materials, from liability for any claims by me or any third party in connection with my participation.

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