Recording & AI documentation — permission discussion

Optional discussion aid. Complete exact service and handling details before requesting permission. No information is recorded, saved or sent by this blank page. Practice review is needed before use.

Consent information

Patient / date / clinicianProposed recording or AI documentation service and providerWhat will be captured; purpose; when recording starts and stopsWho can access the recording, transcript and resulting note; where they are storedRetention / deletion schedule and how to ask questions or withdraw permission

I have had an opportunity to ask about recording, AI assistance and privacy. I may decline recording and discuss care using the available non-recording documentation method. I may ask for recording to stop. The clinician will review documentation for accuracy. My treatment consent does not automatically give permission for recording, model training, advertising or other uses.

Decision: agree for the specified use / decline / agree with these limitsPatient or authorized representative signature / dateRepresentative authority, if applicableClinician confirmation / date