Patient image use authorization template for HOF

November 11, 2026 · 5 min read

Editorial illustration for a patient image use authorization template in HOF

A photo of a face is personal data, and a clinical photo of a patient is health-related data, treated more strictly under the LGPD. That is why taking photos for the medical record, using images in a class and publishing a case are three different things, and each requires clear authorization from the patient, which can be withdrawn.

The template below separates clinical use (medical record) from optional purposes (teaching, scientific publication, promotion), lets the patient tick what they authorize and provides for revocation. It is generic: adjust it to your practice and have a lawyer review it. To understand the concept, read image use authorization.

When should you use this template?

Before taking the patient's first photo, together with the procedure's informed consent, but in a separate document or block. Ask for new authorization when the purpose changes (for example, moving from the medical record to promotion). For the technical standard of the photos, see standardized clinical photography.

How do you adapt it?

Keep clinical use separate from the rest. No patient should have to accept promotion in order to be treated.
List only the purposes you actually use. An overly generic purpose ("any use") weakens the authorization.
Write down where the images will be stored, who has access and for how long.
Define how the patient requests withdrawal of the authorization: channel, response time and what happens to the material.
Handle minors and persons without legal capacity with care: the authorization comes from the legal guardian, and publication should be assessed even more strictly.
Follow your professional board's advertising rules. The form does not replace them. See what you can publish (CFO and CONAR).
AI-generated simulations (like Harmy's) are illustrative and must never be presented as an actual result.

What must never be missing?

Item	Reason
Types of image (photo, video, simulation)	Defines what was authorized
Separate, tickable purposes	Free and specific choice
Whether the face appears in full or protected	Reduces the risk of identification
Where, for how long and who has access	Transparency and security
Right to revoke and a channel to do so	Provided for in the LGPD
That refusal does not affect care	Free authorization
Place, date and signatures	Validity

Image use authorization template

Template

IMAGE USE AUTHORIZATION FORM

Patient: ________

CPF (Brazilian taxpayer ID): ________

Legal guardian (if the patient is a minor or lacks legal capacity): ________

Responsible professional or clinic: ________

Professional board and registration number: ________

1. Images covered

This form covers photographs, videos and images generated from them (such as illustrative simulations) of my face and body, taken during my care.

2. Clinical use (necessary for care)

I authorize my images to be recorded and used in my medical record, for assessment, planning, follow-up and comparison of my progress. They will be stored with restricted access, for: ________, in accordance with the applicable rules, and will not be shared outside the team without my authorization or legal provision.

3. Optional uses

The uses below are optional. I will tick only those I authorize. Ticking none does not affect my care.

( ) Use in teaching, classes and presentations for health professionals, without identifying my name.
( ) Use in scientific publications, without identifying my name.
( ) Promotion on social media and the clinic's website, in accordance with the professional board's rules.
( ) Promotion in the clinic's printed material.
( ) Use of an illustrative simulation generated from my photo, in conversation with me and in material I receive.
( ) Other use (specify): ________

4. Form of display

( ) Full face, identifiable.
( ) Face with a means of preventing identification (for example, a bar or crop).
( ) Only the treated area.

5. Term and scope

The authorization for optional uses is valid for: ________, for the media and places indicated above.

6. Images and results

I understand that images may be used to show a case, but that each person responds differently and that no image represents a promise of results. Simulations are illustrative.

7. My rights and revocation

I know that I may, at any time and at no cost, request information about the use of my images and revoke this authorization, in whole or in part, by contacting: ________. After the request, the clinic will stop using my images for the revoked purposes and will do what it can to remove what is under its control, within the limits of the law. Revocation does not affect my care.

8. Data protection

My data and images will be processed in accordance with Brazil's General Data Protection Law (LGPD). The party responsible for processing is: ________.

9. Declaration

I have read this form, or it was read to me, I had the opportunity to ask questions, and I decide freely regarding the authorizations ticked above.

Place and date: ________

Patient or legal guardian signature: ________

Professional signature: ________

Where is the legal basis?

Brazil's General Data Protection Law (Law 13,709/2018) covers consent, revocation and the data subject's rights. For the clinic's photo routine, see also consent and LGPD for photos and medical records and documentation in HOF.

Frequently asked questions

What is the difference between an image use authorization and procedure consent?

Procedure consent deals with the risks and the decision to have the treatment. An image use authorization deals with something else: whether and how the patient's photos and videos may be used. Mixing the two can undermine the patient's free choice, so it is best to keep separate documents or separate options.

Can the patient withdraw the image use authorization?

In general, yes. Brazil's LGPD (General Data Protection Law) provides that consent can be revoked through a simple procedure, and the form should say so and explain how to make the request. The effect on material already published should be assessed with a lawyer.

Can I use the patient's photo on Instagram if they sign the form?

The signature is necessary but not sufficient: publication must also respect the advertising rules of your professional board and the CONAR rules (Brazil's advertising self-regulation body). See what is usually allowed in what you can publish, and consult your professional board.

Terms mentioned

Image release form LGPD in facial harmonization Informed consent in orofacial harmonization Illustrative simulation Patient record in facial harmonization