Is an electronic signature valid on consent?

Yes. Under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, electronic signatures are legally binding when intent, consent, attribution, and record retention are present.

When is HIPAA authorization required?

A separate HIPAA authorization is required when images are used for marketing or shared beyond treatment purposes; include required elements and retain per 45 CFR §164.508.

Can a patient revoke consent later?

Generally yes; specify revocation procedure in the form. Note practical limits where images have been published or shared with third parties and cannot be fully withdrawn.

Do minors need guardian signatures?

Yes. A parent or legal guardian must sign for minors unless state law provides otherwise; document guardian relationship and age at signature.

Is notarization required for images?

Not typically required for clinical consents. Notarization or RON may be chosen for higher evidentiary weight or legal proceedings; state rules vary.

How should signed consents be stored?

Store consents with the patient record in a secure system with access controls and audit logs. Retention should meet HIPAA (45 CFR §164.530(j)) and any applicable state or federal recordkeeping rules.

Electronic Signature
Templates
Healthcare
Informed Consent for Image Treatments

Informed Consent for Image Treatments

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT PHOTOGRAPHIC AND/OR VIDEO IMAGES

AUTHORIZATION:

I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.

PURPOSE:

The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising

REVOCABILITY:

I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.

NO TREATMENT CONDITIONS:

I understand that the practice cannot condition treatment on whether or not I sign this authorization.

IF DESIRED, COPY PROVIDED:

“Yes, I would like a copy of this form.”
(initialed by team member, copy provided by )

PRACTICE NAME:

DATE:

SIGNATURE:

IF PERSONAL REPRESENTATIVE

NAME:

DATE:

SIGNATURE:

RELATIONSHIP TO PATIENT:

IF PATIENT IS A MINOR

PARENT / LEGAL GUARDIAN:

DATE:

SIGNATURE:

This form is provided by My Social Practice for general convenience purposes and does not represent legal advice. Additional compliance rules vary from state to state, country to country. If you feel like you need legal consultation in addition to what we’ve provided, be sure to consult your practice attorney including seeking advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services regulations. My Social Practice is a social media marketing company. We are NOT attorneys, and although this form is based on our own research to ensure compliance, it does not represent legal advice.

You may download this form as a PDF, at no charge, for printing yourself at: MySocialPractice.com/hipaaform

INDEMNITY FORM / CLIENT CONFIDENTIALITY FORM

Client Name:

Please circle: Male Female

Salon Name:

Any medications:

SIGNATURE:

BEAUTY PROFESSIONALS NOTES:

TREATMENT BEING PERFORMED:

DATE:

Other relevant information:

Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?

Please circle: NO YES – which treatment?

Did you experience any reaction to theses treatments?

Please circle: NO YES – which treatment?

Please provide details of this reaction:

Did you seek medical advise from a doctor or specialist as a result of this reaction?

Please circle: NO YES – what was the advise of your doctor/treatment given:

Skin Disorders Inflammation of the skin Eye disease

Blephartitis Allergies Contact lenses

Allergies to acetone Are you taking HRT? Recent eye surgery

Hayfever Previous reactions to eye treatments Allergies to adhesives, glues or bonding agents

Are you pregnant or lactating? Allergies to latex/band aids

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

SIGNATURE:

DATE:

BEAUTY PROFESSIONALS NOTES:

TREATMENT BEING PERFORMED:

What the Informed Consent for Image Treatments Is

An Informed Consent for Image Treatments is a patient-facing legal document that explains a proposed photographic or imaging procedure, its purpose, risks, benefits, alternatives, and how images will be used, stored, and shared. It documents the patient's voluntary agreement to proceed after receiving information necessary to make an educated decision. The form typically records patient identity, treatment details, duration, contact information, and signature, and may include HIPAA-compliant authorizations when images contain protected health information. Properly completed consent protects patient autonomy and supports clinical and administrative recordkeeping.

Why a Clear Consent Form Matters

A precise, documented consent reduces legal risk, clarifies expectations for care and image use, and supports compliance with health privacy and consumer disclosure rules.

Who Prepares and Signs This Consent

Clinics, dermatology and plastic surgery practices, medical photographers, research teams, and aesthetic providers commonly use this form to obtain documented patient permission.

Patients and legal guardians: sign to authorize use, storage, and sharing of images under stated terms.
Clinicians and photographers: complete treatment description, date, and contact details for follow-up and documentation.
Medical records or compliance staff: retain the signed consent in the patient record and manage access controls.

The form clarifies roles and creates an auditable record for clinical, legal, and administrative needs.

Step-by-Step: Completing the Consent with the Patient

Use this sequence during the patient interaction to document informed consent consistently and reduce follow-up questions.

01

Explain Procedure: Describe the imaging method, purpose, and expected duration in plain language.
02

Describe Risks: Cover foreseeable privacy risks, incidental findings, and potential image misuse scenarios.
03

Discuss Alternatives: Offer alternative options, including declining images or using anonymized images.
04

Obtain Signature: Collect dated signature and record authentication method (e.g., e-sign with audit trail).

Typical Workflow for Image Consent and Handling

A consistent workflow ensures informed decision-making, secure storage, and proper use of images across clinical and administrative teams.

Request Consent: Initiate before any imaging; provide patient with form and disclosure about electronic records.
Capture Images: Take photos per clinical protocol and tag images to patient record immediately.
Record Consent: Attach signed consent to patient chart and link to image metadata for provenance.
Control Access: Limit image access to authorized staff; log all access and disclosures.

How to Configure an Electronic Consent Workflow

Set up fields and authentication to balance low signer friction with adequate proof of identity and intent.

Field	Configuration
Patient Details	Required fields, autofill from EHR where available
Consent Options	Checkboxes for uses; required selection to proceed
Authentication	Email link or SMS code; stronger KBA for sensitive use
Audit Trail	Capture IP, timestamp, and signer attribution

Technical Considerations for eSigning Image Consent

Choose platforms that preserve an auditable record and meet applicable privacy and signature laws.

File Formats: Accept PDFs and image files with embedded metadata.
Authentication: Support email, SMS, or stronger identity verification.
Audit Logs: Store timestamps, IPs, and signer actions.

Ensure the platform supports retention, secure storage, and HIPAA-compliant workflows where required.

Essential Elements to Include in a Professional Consent

A robust consent template covers legal, clinical, and data-handling topics so the signer understands purpose, limits, and their rights.

Purpose

State why images are taken and how they will support care or evaluation, including research or education if relevant.

Scope of Use

Define permitted uses such as internal care, training, publications, or marketing with separate opt-in options.

Privacy Protections

Explain storage location, access controls, de-identification options, and any third-party sharing.

Risks and Limits

Describe foreseeable risks including re-identification and limitations of confidentiality.

Revocation Rights

State how and when consent may be withdrawn and practical limits on withdrawal for already-published images.

Signatory Details

Provide name, relationship, date, and method of signature, including guardian or legal representative info when applicable.

Required Identifying and Administrative Data

Patient Name: Full legal name on record.

Date of Birth: MM/DD/YYYY for identification.

Treatment Date: Date imaging occurred.

Purpose Statement: Short description of image use.

Signer Role: Patient, guardian, or authorized rep.

Authentication Method: E-sign audit trail or notarization noted.

Key Risks When Consent Is Incomplete or Incorrect

Privacy Breach: Unauthorized disclosure of PHI.

Regulatory Penalties: HIPAA fines for improper handling.

Civil Liability: Claims for misuse or misrepresentation.

Invalid Consent: Ambiguous forms may be unenforceable.

Research Noncompliance: Loss of IRB approval, funding risk.

Reputational Harm: Patient trust and public confidence loss.

Common Preparation Errors to Avoid

Using vague language about image use rather than specific categories.
Failing to document the signer’s identity verification method.
Neglecting to offer a separate opt-in for marketing or publication.
Storing signed consents without linking them to image metadata.

Timing Considerations and Typical Deadlines

Timely execution and storage of consent forms affects treatment scheduling, research timelines, and regulatory compliance.

Before Imaging:

Obtain signed consent prior to taking any images unless emergency care necessitates delay.

Research Enrollment:

Capture consent per IRB schedule before study procedures commence.

Publication Lead Time:

Secure publication consents well before submission to allow editorial review and revisions.

Revocation Requests:

Respond to withdrawal requests per policy; note limits if images are already published.

Record Retention:

Ensure consent stored according to retention timeline and accessible for audits.

eSignature Pricing and Feature Comparison Relevant to Consent Workflows

Comparing entry pricing and core features helps practices choose a platform that supports HIPAA workflows, bulk sends, and audit trails without unexpected envelope limits.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Trial available	Trial available	Trial available	Trial available
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About Image Consent

Answers to common legal, technical, and procedural questions about obtaining, eSigning, and managing image consents.

Need help? Contact support

Is an electronic signature valid on consent?
Yes. Under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, electronic signatures are legally binding when intent, consent, attribution, and record retention are present.
When is HIPAA authorization required?
A separate HIPAA authorization is required when images are used for marketing or shared beyond treatment purposes; include required elements and retain per 45 CFR §164.508.
Can a patient revoke consent later?
Generally yes; specify revocation procedure in the form. Note practical limits where images have been published or shared with third parties and cannot be fully withdrawn.
Do minors need guardian signatures?
Yes. A parent or legal guardian must sign for minors unless state law provides otherwise; document guardian relationship and age at signature.
Is notarization required for images?
Not typically required for clinical consents. Notarization or RON may be chosen for higher evidentiary weight or legal proceedings; state rules vary.
How should signed consents be stored?
Store consents with the patient record in a secure system with access controls and audit logs. Retention should meet HIPAA (45 CFR §164.530(j)) and any applicable state or federal recordkeeping rules.

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