Consent to use of clinical photographs Your name Title Title - None -MissMsMrMrsDrOther… Enter other… First Middle Last Date of birth I authorise the use of my clinical photographs by the staff or agents of Spot Check Clinic. I understand that identifying information such as my name or images of my face will not be used unless I give my explicit consent for the use of such photographs. I consent for my photographs to be used for the following purposes. Please select "Yes" for each case where you give consent. Educational use Yes No For example, teaching of Spot Check Clinic staff, other health professionals and students, education of Spot Check Clinic patients and prospective patients. Research use Yes No For example, publication in research articles/papers, presentation at academic conferences and meetings. evaluation of new photographic/analytics technologies Website and social media Yes No For example, to provide information about conditions, investigations and treatments on our website, to draw attention to skin cancer and related issues on Facebook, Twitter, Instagram, Google and other social media accounts operated by Spot Check Clinic. I consent to the use of photographs with identifying information Not applicable No identifying features appear in my clinical photographs No I do not consent to the use of clinical photographs containing identifying features Yes I acknowledge that Spot Check Clinic proposes to use clinical photographs that may identify me. I have viewed these photographs and consent to their use for the purposes specified above. By consenting to the above, I understand that: I will receive no payment from any party. Withholding consent will in no way affect the medical care I will receive. If I wish to withdraw my consent in the future, I may do so by contacting Spot Check Clinic. Your signature Please sign above, using your mouse, finger or a stylus DescriptionComplete this form only if your doctor has requested it.