General Hospital • Operating Theatre

Clinical Photography / Video Consent Form

F-OT-23

Patient Name

MRN

Date

Requesting Surgeon / Physician

Procedure

1 Purpose of Recording

I authorize the medical team to take photographs, videos, or other multimedia recordings of my medical condition/surgery for the following specific purposes (Please tick all that apply):

Clinical Documentation To be kept in my medical record to assist in my diagnosis, treatment planning, and continuity of care.

Medical Education / Teaching To be used for training medical staff, students, and healthcare professionals within the institution.

Quality & Research To be used in approved quality improvement projects, scientific publications, or medical conferences.

Marketing / Social Media * Prohibited under OT Policy unless explicit executive approval is attached separately.

2 Patient Acknowledgement & Privacy Protections

By signing this document, I acknowledge and agree to the following terms regarding my privacy, dignity (Awrah protection), and rights:

Identity Protection: I understand that every reasonable effort will be made to conceal my identity. My face, name, and unique birthmarks will be blurred or excluded unless they are the direct focus of the medical condition being treated. Dignity & Modesty: I understand that recording will be restricted strictly to the surgical field. The hospital ensures that my privacy and modesty ("Awrah") will be respected, and unnecessary exposure will be strictly prohibited. Secure Storage: I understand that all recordings will be captured and stored using authorized, secure hospital devices and systems. Staff are strictly prohibited from using personal mobile phones for recording. Voluntary Consent: I understand that my consent is entirely voluntary. If I refuse, it will not affect the quality or availability of my medical care in any way.

Declarations & Signatures

Patient / Legal Guardian

Name

Relationship (if not patient)

Signature

Date

Explaining Physician / Surgeon

I confirm that I have explained the purpose, boundaries, and privacy protections of this recording to the patient/guardian and answered all their questions.

Name / ID

Signature

Date

Interpreter / Witness (If Applicable)

Right to Revoke

You have the right to withdraw this consent at any time before the recording is utilized for its intended purpose (e.g., publication). To revoke, contact the hospital Patient Relations or HIM department.