Patient Consent Form

Recording of a Consultation for Training

Patient name: ___________________________

Date: ___________________________

Doctor / Student name: ___________________________

Practice: ___________________________

  • We would like to record video of your consultation.
  • This is for training purposes.
  • Intimate examinations will not be recorded and the recording will be stopped if requested.
  • The recording will only be retained while educationally useful, then deleted.
  • You have the right to withdraw consent at any time by contacting the practice. The recording will then be deleted.
  • The doctor may share the recording with colleagues who can provide them with educational feedback.
  • If a mobile device is used to make the recording, it will be securely uploaded after the consultation and removed from the device.
  • The recording may be analysed using secure Artificial Intelligence tools to support the doctor's learning. The recording and any data will remain confidential.

I have read and understood the above and consent to my consultation being recorded under these terms.

I consent to the use of AI tools: Yes / No

BEFORE CONSULTATION

Signature: ___________________________ Date: ___________________________

AFTER CONSULTATION

Signature: ___________________________ Date: ___________________________