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I give permission to ___________________________.

(Name of facility)

to use materials identifying____________________ in the following situations: (Name of client)

_____External publications (e.g., professional journals, newspapers, magazines)

_____Radio programs

_____Television programs

_____Internal publications (e.g., facility publications)

_____Internal/residential building displays (e.g., bulletin boards, photo albums)

_____Conference materials (e.g., slides, overheads)



In many cases, the use of the patient’s (client’s) first and last name is not necessary, but can add to the completion of the story or photo. If you do not want the last name used, please indicate below:

_____NO, the use of first and last name is not permissible

_____YES, the first and last names may be used

_____Only the first name and last initial may be used

I give consent on the condition that the material be used only for the above purpose(s). It is my understanding that I may see the materials before confirming consent or before the material is released. Also, it is my understanding that I will receive verbal notification before any material is used, and that I may place the following restrictions on the material or its use, including time limits:

I give this consent voluntarily, without threat of punishment or promise of special reward. I have been given an opportunity to fully discuss the release and to have my questions answered. I understand that I may withdraw consent at any time prior to release without fear or punishment.

Signature: ____________________ Date:__________


Signature: ____________________ Date:__________

(Parent or Guardian, if applicable)

I have fully explained the information above and answered all questions to the best of my ability. It is my opinion that consent has been given knowingly and freely.

Signature: ____________________ Date:__________

(Person obtaining consent)


(Title or position)

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