DFS - Clients - Consultation Recording Consent Form

Consultation Recording Consent Form

Client Email Address *

This permission is to be granted for the following duration of time:

For the duration of treatmentUntil revokedUntil specified date

By whom? *

What date? *

Dates / sessions to be excluded from recording(If applicable)

Choose your nearest DFS clinic *

We would be grateful if you would fill in this form to give us permission to record you / your child’s appointments and consultations at Direct Focus Solutions.

These recordings may be conducted in one or more of the following ways (as agreed between practitioner and the client and/or their representative):

Audio (phone, computer capture, or dedicated recording device)
Video (phone, computer capture, or dedicated video capture device – camcorder, etc.)

By signing this form, I give permission for Direct Focus Solutions (DFS) to:

Take audio and/or video recordings of myself / my child during appointments and consultations *

Maintain a secure copy of any recordings taken for the duration of the client’s services at DFS *

Transmit a copy of recordings to one or more of the individuals listed below: *

1. *

2.

3.

4.

5.

Name of Client *

Client Signature

(As applicable)

Name of Parent / Guardian(As applicable)

Parent / Guardian Signature

(As applicable)