Photography & Social Media Authorization
Patient Name: _______________________________________________
Date of Birth: _______________________________________________
Date: ______________________
Photography Consent
At LumiLife Aesthetics + Wellness, clinical photography is an important part of medical documentation and treatment planning. Photographs help your physician evaluate treatment areas, monitor progress over time, and maintain an accurate medical record.
Your privacy is important to us.
This authorization allows you to choose whether your photographs may be used beyond your confidential medical record.
Your decision will not affect your care, treatment recommendations, or relationship with LumiLife Aesthetics + Wellness.
Medical Record Photography
I understand that photographs may be taken before, during, and after treatment for the purpose of:
✓ Medical documentation
✓ Treatment planning
✓ Monitoring treatment progress
✓ Maintaining an accurate medical record
These photographs become part of my confidential medical record and are protected in accordance with applicable privacy laws, including HIPAA.
Medical Record Photography
☐ I consent
☐ I do not consent
(Please note that certain treatments may require clinical photographs to ensure safe and appropriate medical care.)
Optional Authorization for Educational & Marketing Use
I understand that I may voluntarily authorize LumiLife Aesthetics + Wellness to use my photographs for educational or marketing purposes.
This authorization is entirely optional.
I understand that declining authorization will not affect my care or treatment in any way.
Please indicate your preferences below.
Website
I authorize LumiLife Aesthetics + Wellness to use my photographs on its website.
☐ Yes
☐ No
Social Media
I authorize the use of my photographs on LumiLife’s social media platforms (including Instagram, Facebook, TikTok, YouTube, and similar platforms).
☐ Yes
☐ No
Educational Presentations
I authorize the use of my photographs for educational lectures, presentations, physician training, and professional education.
☐ Yes
☐ No
Printed Educational Materials
I authorize the use of my photographs in brochures, educational materials, and informational publications.
☐ Yes
☐ No
Before & After Photographs
I authorize the use of my before-and-after treatment photographs for patient education and marketing.
☐ Yes
☐ No
Identity Preferences
Please indicate how you would like your photographs to be presented.
☐ Full face may be shown.
☐ Only treatment area may be shown.
☐ Eyes should be covered or otherwise de-identified whenever reasonably possible.
☐ I prefer that no personally identifying features be visible.
While LumiLife Aesthetics + Wellness will make reasonable efforts to honor these preferences, complete anonymity cannot always be guaranteed, particularly when facial features are visible.
Understanding
I understand that:
- My participation is completely voluntary.
- I may refuse authorization without affecting my medical care.
- I will not receive financial compensation for the use of my photographs.
- Once photographs have been published in printed materials or online, they may be copied, shared, or redistributed by others beyond the control of LumiLife Aesthetics + Wellness.
- LumiLife Aesthetics + Wellness cannot guarantee that third parties will not download, copy, or share publicly available images.
Revocation of Authorization
I understand that I may revoke this authorization at any time by providing written notice to LumiLife Aesthetics + Wellness.
Revocation will apply only to future use of my photographs.
It cannot apply to materials that have already been published, printed, or otherwise distributed before the revocation was received.
Patient Authorization
I have read and understand this Photography & Social Media Authorization.
I have had the opportunity to ask questions.
I voluntarily authorize the use of my photographs according to the selections I have made above.
Patient Name
_______________________________________________
Patient Signature
_______________________________________________
Date
_______________________________________________
Witness / Staff Member
_______________________________________________
Date
_______________________________________________
LumiLife Aesthetics + Wellness
225 Main Street, Office #7
Westport, CT 06880
Phone: (203) 557-3144
Email: info@lumilifeaw.com
