Consent for Photography and Videography of Condition 

Consent and Acknowledgment for Use of Images and Videos Taken During Medical Examination and Treatment at Rainville Foot Health

I hereby acknowledge and consent to taking photographs and/or videos during my medical examination and treatment at Rainville Foot Health. I understand these images and videos are used for my medical care, which includes diagnosis, treatment planning, and consultations with other healthcare professionals involved with your care.

I also agree that these images and videos might be used for educational or training purposes within the medical community, ensuring my personal identity is kept confidential unless I provide explicit permission otherwise. (Rainville Foot Health is a teaching facility that hosts NOSM and Chiropody Students) 

I have been fully informed about the purpose and process of taking these images and videos and have had the chance to ask any questions. By signing below, I give my consent to the use of my pictures and videos as described above.

I acknowledge and agree to adhere to the Pic In Chart Policy. I understand that should I not accept this policy, the practice reserves the right to reassess my eligibility for care.   You will be asked to physically sign this form before your appointment.