You Little Gem Clinic ◇ Benign Skin Lesion Removal

Photography, Video and Social Media

Optional consent form

Important: This consent is completely optional. Refusing or withdrawing promotional consent will not affect your assessment, treatment or care.

Full name

Date of birth

Telephone / email

Close-up photographs of the lesion / treatment area

Before-and-after photographs

Photographs showing my face or identifying features

Video of the treatment area or procedure

Video or audio in which my face or voice is identifiable

Written testimonial or quotation approved by me

Any limits or areas that must not be shown

You Little Gem Clinic Facebook page

You Little Gem Clinic Instagram account

You Little Gem Clinic TikTok account

You Little Gem Clinic website / online pages

Google Business Profile or other clinic listing

Printed clinic information or advertising

Professional education or training materials

Other agreed use

My images may be used without my name

My first name may be used

My face / identifying features must be cropped or obscured

I agree that my face / identifying features may be visible

Online material may be viewed, copied, saved, shared or reposted.
Your full name or unrelated health information will not be used without separate written permission.
Images may be adjusted for layout but must not be altered in a misleading way.
You may withdraw consent for future use. Material controlled by the clinic will be removed where reasonably possible, but copies already shared or cached cannot always be recovered.

Consent continues until I withdraw it

Consent applies only until the date below

End date

I have read and understood this form

I understand promotional consent is voluntary and separate from treatment

I have ticked the exact recordings, uses and identification choices I authorise

I consent to the selected uses

Patient / representative signature / date

Patient aged under 18 — assent where appropriate / date

Practitioner: Gemma Lacy / date