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The Medical Photo Consent Form is a critical document required in Indonesian healthcare settings whenever medical photographs need to be taken of patients for various purposes including treatment documentation, education, or research. This document is essential for compliance with Indonesian healthcare regulations, particularly Law No. 36 of 2009 on Health and Law No. 29 of 2004 on Medical Practice, which mandate proper informed consent for medical procedures and documentation. The form should be used prior to any medical photography session and includes specific details about the nature of photographs to be taken, their intended use, storage protocols, and privacy protections. It serves as a legal record of patient consent and helps healthcare providers maintain proper documentation while protecting both patient privacy rights and the facility's legal interests.

1. Title and Date: Clear identification of the document as a Medical Photo Consent Form and date of execution

2. Patient Information: Full name, date of birth, contact details, and medical record number of the patient

3. Healthcare Provider Information: Name and details of the healthcare facility and attending medical professional

4. Purpose of Photography: Clear explanation of why the medical photographs are being taken and their intended use

5. Scope of Consent: Specific details about what is being photographed and how the images will be used

6. Patient Rights: Statement of patient's rights regarding the photographs, including right to withdraw consent

7. Privacy and Confidentiality: Explanation of how privacy will be maintained and who will have access to the images

8. Storage and Security: Information about how and where the photographs will be stored and secured

9. Duration of Consent: Period for which the consent remains valid

10. Signatures: Space for patient (or legal representative) and healthcare provider signatures, with date