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INFORMED CONSENT FOR IMAGE TREATMENTS

INFORMED CONSENT FOR IMAGE TREATMENTS 2026

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The document is an authorization form for the use and disclosure of patient photographic and video images for marketing purposes related to a lash lift practice. It outlines the patient's consent, revocability of the authorization, and clarifies that treatment is not contingent upon signing the form. Additionally, it includes an indemnity form for client confidentiality, gathering personal information and medical history relevant to potential reactions to beauty treatments.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the practice name at the top of the form. This identifies where your consent is being given.
In the AUTHORIZATION section, provide your name and check the box to authorize the use of your photographic/video images for marketing purposes.
Review the PURPOSE section to understand how your images will be used, such as for social media or advertising.
Fill in the DATE field and sign where indicated. If you are a personal representative, include your name and relationship to the patient.
If applicable, complete the section for minors by providing parent or legal guardian details and signature.
Finally, indicate if you would like a copy of this form by checking 'Yes' and initialing as required.

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