Clinic LGPD data consent form template
An HOF clinic (orofacial harmonization in Brazil) handles sensitive data all the time: health history, medications, allergies, photos of the face, sometimes biometric data. The LGPD, Brazil's data protection law, requires transparency about this. Patients need to know which data is collected, what for, who it is shared with, how long it is kept and how to exercise their rights.
This template is an acknowledgment form and, when needed, a consent form for data processing. It complements the clinic privacy policy, the registration form with LGPD and the image use release.
When should you use this template?
At the first visit, together with registration, before collecting photos and health data. Update it when the clinic changes how it handles data (new system, new purpose, new sharing).
Consent or another legal basis?
| Situation | Most common basis |
|---|---|
| Care, patient chart, health protection | Health protection, does not depend on consent alone |
| Keeping the patient chart | Compliance with a legal or regulatory obligation |
| Clinical photos in the patient chart | Care, subject to legal analysis |
| Photos used in promotion | Specific, separate consent |
| Marketing messages | Consent or another basis, depending on the analysis |
| Payment and billing | Performance of the contract |
See the page on the LGPD legal basis. Choosing the basis is a legal decision, and this template must be adjusted to it.
How do you adapt it?
Clinic LGPD consent form template
Is the form enough to be compliant?
No. Compliance is a routine: internal policy, restricted access to the patient chart, team training, an incident plan. The form is only the visible part. See the topic of sensitive personal data, organize the patient chart with controlled access and use the team social media policy to prevent everyday leaks.
Frequently asked questions
Does all processing of patient data depend on consent?
No. The LGPD (Brazil's General Data Protection Law) provides for other legal bases, such as health protection and compliance with a legal obligation. Consent is used, for example, for additional purposes, such as using images in promotion. Confirm the framework with a specialist.
Are patient photos covered by the same form?
Clinical use of photos may fall under care and the patient chart, but use for promotion requires specific, separate authorization, preferably in the image use release.
Can the patient withdraw consent?
Yes, when the processing is based on consent. The clinic must explain how to make the request and which data it needs to keep because of a legal obligation.