Photography & Media Release — Sample Template
A sample release for using patient photos in marketing — separate from treatment consent, and a starting point for your attorney to adapt.
SAMPLE TEMPLATE ONLY — your attorney must review before any use. This is a SAMPLE starting point provided for general educational purposes only. It is NOT legal or medical advice, is NOT guaranteed to be complete, accurate, or compliant for your state or your specific procedure, and is NOT ready to use as-is. You MUST have your own attorney and medical director review, complete, and adapt it before any use. Bracketed [fields] must be filled in, and the risks listed must be verified by your clinicians as complete and accurate for the specific treatment. It is provided "as is," without warranty of any kind, and the publisher accepts no responsibility or liability for its use.
An original Inside MedSpa template
A sample structure only. Using identifiable patient images for marketing requires specific, documented authorization separate from treatment consent — complete every [bracketed] field and have your attorney adapt and approve it for your state and platforms before any use.
Patient & practice information
Practice / clinic name:
Patient name:
Date of birth:
Date:
What I am authorizing
I authorize [practice name] to photograph and/or video record me in connection with my treatment, and to use those identifiable images for the purpose(s) I select below. I understand this is voluntary and separate from my consent to treatment.
Permitted uses (initial each you authorize)
- Internal records / clinical documentation only
- Practice website and social media
- Advertising and marketing materials
- Educational or professional presentations
My understandings
- This authorization is voluntary; declining will not affect my care.
- I may revoke this authorization in writing for future use, though I understand prior uses may not be retractable.
- I am not entitled to compensation for these uses unless separately agreed in writing.
- My results are individual and may not represent typical outcomes.
Acknowledgments
- I have read and understand this release.
- My questions have been answered.
- I am authorizing voluntarily.
Signatures
Patient (or legal representative) — signature & date
Practice representative — signature & date
SAMPLE TEMPLATE ONLY — your attorney must review before any use. This is a SAMPLE starting point provided for general educational purposes only. It is NOT legal or medical advice, is NOT guaranteed to be complete, accurate, or compliant for your state or your specific procedure, and is NOT ready to use as-is. You MUST have your own attorney and medical director review, complete, and adapt it before any use. Bracketed [fields] must be filled in, and the risks listed must be verified by your clinicians as complete and accurate for the specific treatment. It is provided "as is," without warranty of any kind, and the publisher accepts no responsibility or liability for its use. © 2026 Inside MedSpa.