Image Library - Consent Proforma

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Consent Proforma:

Medical Images – Consent form

Thank you for allowing the use of your images for medical education. This consent form is to inform you about how the images may be used in the future.

The images will primarily be used for the education of doctors and allied medical professionals.

I give my consent for this material to appear in the online encylopaedia and associated publications. I understand the following:

  1. The material will be published without a name attached and every attempt will be made to ensure my anonymity. I understand, however, that complete anonymity cannot be guaranteed. It is possible that somebody somewhere - perhaps, for example, somebody who looked after me if I was in hospital or a relative - may identify me.
  2. The material may be published in the online encyclopaedia at , which has a large worldwide audience. It is viewed mainly by doctors but may be seen by many non-doctors.
  3. The material may be used in presentations which could include members of the public.
  4. The material may also be used in printed publications by
  5. The material will not be used for advertising or packaging.
  6. Future control over the images cannot be guaranteed once they have been published.
  7. If you are consenting on behalf of a child, the images should not be submitted if the child objects, even if you agree.

Your signature confirms that you accept the above and consent to the images being used.

  • You may either print and sign this form, or ‘electronically sign’ and return by email.

I am the: subject / parent (please delete):

  1. Name: ____________
  2. Signature: ____________
  3. Date: ____________ (now please return by mail)


“Electronic signature”: ______________ (please type your name here and state that you accept the above agreement)

Date: _____________

( Then return via email to: )

Administration use only:

  • Number of images submitted:
  • Image naming:
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