Medical Video Consent Form Example

To use someone else’s medical record, you need official permission with the person’s original signature. This document shall be prepared to get the patient consent especially if plan to use the related video and audio for some matters. For example, for advertising, or public information.

Unfortunately, this might be not a common form to develop. Sometimes this is confusing for some people. To help with a sample of this medical video and audio surveillance consent form, the following paragraphs will help to give some overviews.

Sample of Medical Video Consent Form

The following is a nice sample of the medical video consent form. This one is quite common and general. It also can easily copy and paste through Microsoft Word document.

Sample of Medical Video Consent Form


Important Things to Note

The form issuance is basically to get approval consent and authorization from the owner of the video. Therefore, in developing the form, there are several important things to note so that the form will be clear and as per its purpose.

  • For the participant data, it is important to make sure that all the data from the participant is completely written.
  • Date of recording, this also shall be noted in the form to identify when the video/audio is recorded.
  • The name of the party that will distribute the video/audio. It is important to specifically inform the party that will get the authorization.
  • Agreement or statement from the participant. This is the most important sentence to write since this sentence is the basis for the formal authorization from the video/audio owner to the part that will distribute the video/audio. This also a guarantee to make sure that there will be no further legal issues in the future.

printable video consent form



By giving the video consent form above, it will be legal to use any medical video, audio, or record from someone. This also a kind of agreement that a party can use personal video for a specific purpose, such as for information and education.

Furthermore, this form also one of the ways in legalized the activity in spreading any personal medical video. Hence, in the future, there will be no legal issue or possibility of anyone harmed in this matter.

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