About Richard
Conditions Treated
Robotic Surgery
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Clinical Images
Clinical images are an important part of your care. They are vital for your diagnosis and important in tracking changes over time. They may include internal and/or external clinical images, such as videos and photographs, and may be taken during your consultation with A/Prof R Gallagher in the operating theatre when you are under anaesthetic. It is important you know that these images are recorded and stored securely as part of your medical record. Sharing images with other health professionals may also be necessary as part of your medical care. Clinical images are also valuable for teaching and training. We would like to ask your permission to share your clinical images for the purposes of clinician and patient education. All images will be anonymous and all identifiable features will be removed.
Clinical Images Consent Form
Title
Title
Ms
Mrs
Mr
Dr
Other
Name
Date of Birth
I consent to clinical photographs, slides, digital images and/or video to be:
taken as part of my treatment
collected and stored as part of my medical care and treatment
shared with other clinicians involved in my treatment
shared with other health professionals for the purpose of education e.g. at a conference or in an academic journal
shared on A/Prof Gallagher’s publicly accessible website for educational purposes
shared on A/Prof Gallagher’s publicly accessible Twitter page for educational purposes
I acknowledge that:
I have read the above information and have received an explanation about what images will be taken and why.
I am not obligated to agree to have clinical photography taken and I can withdraw my consent at any time without affecting my surgical care or relationship with the practice.
I understand that my photographs will not be used for any other purpose aside from what is set out and consented to above.
understand that my photographs will not be identifiable.
I understand that the clinical images will be archived.
Todays Date
Turing field
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