Photograph Use Consent Form
Your Photos and How We Would Like To Use Them
At Lumiere MediSpa Ltd, we capture before and after treatment photographs during each appointment to monitor treatment progress and maintain your medical aesthetic treatment record. This is a mandatory requirement for receiving treatments at our facility.
On certain occasions, we may seek your consent to share these photographs with other medical professionals, the public, the World Wide Web, social media, and the general media. Sharing serves as an example of the outcomes achievable through our treatments. Please note that sharing photographs is optional and not a mandatory requirement for treatment.
When sharing treatment photographs, we take measures to protect patient anonymity. Identifying features, such as eyes, are blanked out or close-cropped, unless specified otherwise below. No patient identifying information, including names, accompanies released photographs unless specified.
It's important to understand that, despite efforts to protect identity, recognition cannot be guaranteed. Photographs released on the World Wide Web, including social media and websites, may be subject to copying and sharing beyond our control. You retain the right to revoke your consent for photo usage at any time; however, we cannot guarantee the removal of all photos from the World Wide Web due to this revocation.
Lumiere MediSpa does not offer financial incentives to receive your consent to share your photographs and your consent is by free will.
I give my free consent for Lumiere MediSpa Ltd. to use my before and after treatment photographs for the options selected below:
Your Consent To Use Your Photos
Please select where and how we can use your photos
Blank out my eyes for anonymity
I do not want my eyes blanked out for anonymity
You can display my photo on the Lumiere Medispa Clinic Website
You can display my photo on the Lumiere Medispa Social Media Channels - For Education/Promotion
You can display my photo in the Lumiere Medispa In-House Treatment Book
You can display my photo within professional conference presentations
Valid Consent
By signing below, I provide my valid consent for Lumiere Medispa Ltd. to use my photographs for the above-mentioned purposes.
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