Image Consent for Clinical Documentation

Every orofacial harmonization clinic takes photos. What changes from one clinic to another is what is written about those photos. A patient who signed the procedure form thinks "everything is covered". The professional, in turn, sometimes assumes the same signature covers posting the photo on social media. Both assumptions carry risk, and the starting point to fix this is understanding that a chart photo and a publicity photo are not the same thing.

What is the difference between a chart photo and a publicity photo?

The distinction is essential. A patient who agrees to be photographed for their care is not, by that, agreeing to be shown in a post.

What does the LGPD add?

The LGPD (Brazil's General Data Protection Law) asks for purpose, adequacy, necessity, transparency and security. Face photos in a health context can be treated as sensitive data. For the chart, the basis is usually health protection and the record-keeping duty. For publicity, the safest basis is usually specific, free and informed consent.

In other words: the treatment form and the publicity form answer different questions and should be handled as such. For your specific case, consult a legal professional and check the norms of your professional council in Brazil.

What should the documentation image form say?

For the chart, the text should be clear and simple. The points that usually appear:

1. What will be photographed: face, treated areas, standardized views.
2. What for: documenting the starting point, tracking progress, guiding planning and protecting the patient and the professional.
3. Who will have access: the responsible professional and the team involved in care.
4. Where and for how long: storage location and term, per the medical record rules.
5. Sharing: whether a second opinion or referral may happen, and under what conditions (see sharing a photo with another professional).
6. Patient rights: access to the images, information about use and a channel for questions.

How do you explain it to the patient?

The spoken explanation matters as much as the paper. In a few sentences, the patient understands why they are being photographed, and trust grows.

When the patient hesitates, it helps to explain that without the before photo it is harder to document what was done and compare it with the after. Respect the refusal and record it.

What if the patient refuses the photo?

Two decisions are involved: the patient's (who may refuse) and the professional's (who may accept or decline to treat without the record). In risky procedures, documentation is part of treatment safety. Record the refusal in the chart, explain the consequences and decide, at your clinical discretion and per your professional council's norms, whether to treat. More in patient who refuses to be photographed.

How do you store the consent?

• On signed paper or with an electronic signature, dated.
• With the patient's chart, linked to the photos.
• With the version of the form used (if it changed over time).
• With the option the patient checked (accepts or refuses each purpose).

What about consent for the AI projection?

If you use a tool that sends the photo to an AI to generate the projection, the patient also needs to know. In Harmy, the photo is sent to a third-party AI to generate the image, with the professional's acceptance in the app. It is advisable for the clinic's form to mention that the image may be used in an illustrative simulation during planning, and that the simulation is not a promise of results. See also consent and LGPD in patient photos.

Summary for your routine

Inform, record and separate: chart photo in one form, publicity photo in another. Explain to the patient in plain language, keep the consent together with the images and respect refusals and revocations. Good documentation protects the patient, the clinic and the quality of care.

How do you review the form over time?

Forms are not forever. Review the text when the clinic's routine changes, a new tool joins the workflow (such as a projection app), your professional council's norms are updated or the law changes. Keep the version each patient signed and note the date of each revision. An annual review, done with legal support, is usually enough to keep the document aligned with what the clinic actually does.