Photographic Teledermatology Consent Form

I, _______________________, permit the Internet Dermatology Society (IDS) to obtain photographs of myself for educational, medical, scientific, or research purposes.

I agree that the photographs and information relating to my case may be published or used for purposes which the IDS deems proper. These uses may include lectures and professional journals.. However, I shall not be identified by name in any such publication or use. I understand that in some cases my facial features may be visible and/or recognizable.

Photographs shall remain the property of the IDS.

I hereby release the IDS, their personnel, and any other persons participating in my care or dealing with the photographs from any and all liability which may or could arise from the taking or use of such photographs.

_______________________________ Patient's signature*

_______________________________ Witness's signature

____/____/____ Date

_______________________________ Photographer's signature

_______________________________ Parent/Guardian

_______________________________ Relationship

_______________________________ Time Point (baseline, one month, etc.)

_______________________________ Referring Physician

_______________________________ Working Diagnosis

*If the patient is a minor or is unable to consent in writing for any reason, consent must be obtained on the patient's behalf by a parent or legal guardian.

This document is a resource from the Internet Dermatology Society
Send your comments to:
Rhett Drugge, M.D.
Last update: September 11, 1995

Copyright 1995 by the Internet Dermatology Society.