Sample Consent Form

Notice: This sample document and the information in it are presented solely as an example and to be used as a general guide. It is not intended as legal advice. This sample document is not a substitute for legal advice and may not be applicable to, or accurate for, your individual practice setting. By using this sample document, you hereby agree to release and hold harmless Eleos Health, Inc., from any liability arising under or relating to this “Sample Consent Form for Recording” document, whether arising in contract, equity, tort, or otherwise. 


[Enter the clinic’s name here]

[Enter the clinician/provider name here]

I, ___________, agree to participate in treatment that involves video and/or audio recording of services.

_______________

Client’s Full Name

_______________

Client’s Consenting Adult Full Name
(if minor)

________________

Relationship

________________

Relationship

I understand that services will be recorded (audio and/or video) and observed solely by my clinician. This will not be valid only in the case I have expressly consented and signed a release of information for others to view my recording, or unless another exception to confidentiality applies. I understand that recordings may include protected health information that is protected under HIPAA. I understand that the maintenance of this recording as a health record is the responsibility of my clinician and/or their clinic and follows the guidelines outlined in the general clinic consent form. 

My agreement and participation or that of listed family members are knowing and voluntary. Further, I understand that I may withdraw my consent for recording or ask questions about my recording at any time. I acknowledge that I have been provided with a HIPAA Notice of Privacy Practices.  


Client Signature




Client/Legal Guardian Signature
(if client is a minor)


Clinician Signature


Date


Date





Date

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