Informed consent for use of patient’s personal and clinical information and images
(including photographs, case studies and films)
Background and rationale
Several patient advocate organizations have become aligned with the Safety Across the Board
Pledge of Partnership. We seek to convey in person, by voice, and in words, pictures, film and
other audio and visual media the impact on patients and families made by preventable harm
in health care. We also seek to draw attention to patient and family advocates who are
making a difference. For these purposes we seek permission to use your stories,
presentations, any personal and clinical information you wish to share with us that is not
confidential, as well as any images you provide, such as photographs, films, video footage. We
seek this permission from patients or their parents or guardians who have the legal right to
give permission.
Procedure
Sharing or allowing your information to be shared is a voluntary decision. You have the power
to choose to share all or part of your information and/or images. You may choose to share
your experience anonymously or to be identified by name. This is entirely up to you.
For patient advocates who are minors, that is those who are younger than 18 years, we would
ask parents or guardians to complete the informed consent form. When you become 18 years
of age, we invite you to renew your permission by signing an informed consent form in your
own name.
For patient advocates who share the experiences or images of family members, including
family members who are deceased, we ask you to certify that you have permission to share
such experiences or images.
Your contribution is completely voluntary. Should you change your mind later, you can
withdraw your permission by informing us in writing.
For further information or clarification
If you have any questions or would like to discuss any aspect of our use of your material, you
may contact:
____________________________________________________________________________________________________
Declaration of consent: information, photographs, case studies and films
I confirm that I have read or have had read to me the Background and
Rationale and Procedure portions of this consent form. I am an adult (aged 18 years or older)
and have the full right to make this declaration of consent. If I include the names or images of
family members, I declare that I have either their permission to do so or the legal right to do
so as their parent, guardian or survivor.
I understand that that permitting use of my experience in any form (information or images) is
voluntary and that I will not be entitled to receive any payment for their use. I understand
that I can withdraw my consent at any time by notifying _____________________________ in writing.
I give permission to ________________________________________ to make editorial decisions to use or
not to use any of the above. The use of the above may include, but is not limited to, editing,
duplication, licensing, distribution and incorporation in other works, in whatever form (e.g.
hard copy or electronic), such as posters, presentations, publications, web sites, films or
videos, and their unrestricted use, without any obligation on the part of ________________ to seek
further authorization for each use.
I acknowledge that an unrestricted right to use the aforesaid information, photographs, case
studies or films is licensed to _________________________, which shall have the sub-licensable and
worldwide right to use the materials provided in any manner whatsoever. However, nothing
in this declaration shall transfer ownership or prohibit me from using information or images I
provide in my own life and work or with other organizations.
For the purpose of this consent form I am consenting for the use of information and/or
images of: (Please tick the appropriate box)
myself
a minor for who I am parent/guardian
family members described in written materials and/or pictured in images
I consent for __________________________________________________ to use the following:
(Please check all that apply)
My name (that is to be identified by name if it so required)
Personal/clinical information
Photographs
Video footage
I do not consent to ___________________________________________ using any of the above.
I, the undersigned, hereby consent to the use of my likeness, biography, pictures,
presentations and other materials related to myself, a minor for whom I am responsible or
other persons who might be deceased, for use in reports, presentations, publications
photographs, case studies and films made by or for __________________________________________.
Signature: ...................................................
Date: ......................................................
Name: .........................................................
Place: ....................................................
[You may type your name and then send by email. Please send it by yourself as your email will
be considered a part of your signature.]