This form is to take the consent of the patient for recording audio, video & picture if required.

FertiClinic respects the confidentiality of information and governs when and under what circumstances information may be recorded and how permission will be obtained. It is the center policy to comply fully with all legislation pertaining to the rights of the patient and to act in an ethical and responsible manner in maintaining the security and integrity of all personal information

*  if recording VOICE/VIDEO it will be saved on the patient’s medical record which is accessed only by the authorized person.

In addition, I waive any right to inspect or approve the finished video recording.