This patient signed a consent form a blank copy of which is pasted below:

Consent Form for Clinical Photography

• Your clinician would like to take a photograph

• The image may be used for teaching purposes in a healthcare environment (e.g. a lecture or teaching session with students or junior doctors), in presentations for medical conferences, in professional medical publications (including journals and textbooks), or in websites (e.g. medical articles on Wikipedia under the Creative Commons Attribution-Share Alike 3.0 Unported copyright license*)

• The image will be taken on a mobile device and then promptly transferred to a secure hard drive along with an electronic copy of this form to be stored for reference

• You will NEVER be personally identifiable from the image, and you can view it after it has been taken to check you are happy with it

• Your personal information, such as name and address will NEVER be disclosed with the image. Very general details, such as your rough age and gender may be disclosed. Some medical details about what is shown in the image may also be disclosed, e.g. the diagnosis or appropriate terminology describing the appearance

I understand and consent to the above

Patient name …………………………………………

Signed (patient / parent / legal guardian) …………………………………………

Signed (clinician) …………………………………………

Date …………………………………………

• CC BY-SA 3.0 for details please see: