The text of the consent form used for video recording
| Name and address, date of birth and telephone number:- | |
| General information sheet | Please delete the yes or no answer |
| Teaching medical students, doctors often need to use photographs, video recording and other images to demonstrate what a particular illness looks like and how to treat it. This helps medical students and graduates to understand the medical problems suffered by many of the patients that they will meet during their training after they have qualified as doctors With your consent, we would like to make use of video recordings which refers to you and your treatment. When images are shown, you will never be referred to by name and every effort will be made to ensure confidentiality and privacy. If you are happy for us to use your image in teaching student doctors, we would like you to confirm that you have given us your consent by completing the accompanying consent form. Please note that you do not have to give your consent. If you do not wish to give your consent, it will not affect the quality of care you will receive in any way. If you need more information, you can talk to the person who gave you this information sheet. They will do their best to answer any questions you may have. Thank you for taking the time to read this information sheet, and for your help in teaching student doctors and postgraduates. | Do you understand that these images may be used in teaching student doctors and may be stored electronically for that purpose? (yes) (no) |
| Do you consent to the images being used for research purposes and in the teaching of student doctors? (yes) (no) | |
| Do you consent to the images being used in educational publications aimed at student doctors and qualified doctors?* (yes) (no) | |
| Do you consent to the images being used on password protected Internet educational sites aimed at medical students and qualified doctors?* (yes) (no) | |
| Do you consent to the images being used in educational presentations aimed at qualified doctors by the pharmaceutical industry? (yes) (no) | |
| Do you understand that if you change your mind about the use of your images, we will do our best to respond to respect your wishes? (yes) (no) | |
| Have you had an opportunity to ask for further information if you have any questions about this consent form? (yes) (no) | |
| Thank you for taking the time to read and complete this form. For further information please contact | |
*This means that you release the moral rights—the contribution you have made to the film for publication, and that multiple copies can be made.