Templates · Free template · Photography
Before & After Photo Consent Form Template
A printable photo consent form for med spas, injectors, and aestheticians. Clinical photos and marketing use are separate choices, each marketing channel gets its own checkbox, and the right to withdraw is stated in plain language.
Two permissions, not one
Taking a photo for the patient's record and posting that photo on your website are different uses of personal information, and they need different consent. Clinical photos document the baseline and the result, and they belong in the chart. Marketing use is a commercial purpose that the patient can reasonably refuse without it affecting their care.
Most complaints about before-and-after photos start when these two are combined in a single signature. A patient who agreed to clinical photos finds herself on Instagram and doesn't remember saying yes to that. A form that separates the two, and splits marketing into specific channels, prevents most of those conversations.
What Canadian privacy law expects
Under PIPEDA, and the provincial health privacy laws that apply in several provinces, consent has to be meaningful. The person should understand what will be collected, how it will be used, and who will see it. They can also withdraw consent later, subject to legal or contractual limits. That last point matters for marketing: you can stop future use of a photo, but you cannot recall a brochure that has already been printed, so say so on the form.
Record how photos are stored and who can access them. Photos on a practitioner's personal phone are a common gap. Storing them in the patient record, encrypted and in Canada, answers most of the questions a patient or regulator is likely to ask.
Consent for Clinical and Promotional Photography
Patient details
Clinical photographs
Clinical photos are used to plan treatment and document results. They are stored in your patient record and are not shared outside the clinic without your consent or as required by law.
- I consent to clinical photographs being taken and kept in my record
- I do not consent to clinical photographs
Promotional use (optional)
Saying no does not affect your treatment in any way. Tick only the uses you agree to.
- Clinic website
- Clinic social media
- Printed materials in the clinic
- Professional education and training
- Paid advertising
- Face or identifying features obscured only
- Identifiable photos are acceptable
- Treatment area only (no face)
- Do not use my name
- First name only
- Treatment details may be described
Acknowledgements
Signatures
Template from zdrovia.ca/templates/before-and-after-photo-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.
Send this form before the appointment instead of printing it
Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for med spas.
Frequently asked questions
Do I need separate consent for social media?
Yes. Consent should be specific to the purpose. Clinical documentation, your website, social media, and paid advertising are different uses, and patients should be able to agree to some and not others.
Can a patient withdraw photo consent after I've posted the photo?
Yes. Under Canadian privacy law a patient can withdraw consent, subject to legal or contractual limits. Remove the photo from channels you control and stop future use. Printed or already distributed materials usually can't be recalled, which is why the form says so up front.
How long should I keep clinical photos?
Clinical photos are part of the health record, so keep them for the same period as the rest of the chart under your college's record-retention rules. Marketing copies can be deleted when consent is withdrawn.
Related
This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.