1. Speech and Language Therapy Service Consent (Form B) Recording for teaching people It is ok for you to take a Photograph Recording of my voice Video    Version 31 October 2012 Other images labelled for re-use found using http://search.creativecommons.org/ http://search.creativecommons.org/

2. I understand It will be destroyed when it is not needed At any time I can say Do not use the recording Do not keep the recording The recording will be kept safe  The recording will teach people about health care It will be used for …………………….... …………………………………………….. It will NOT be used for anything else 

3. Signature: Print Name: Signature of Carer/Parent/Guardian Name of Carer/Parent/Guardian: Therapist: Date: Therapist please note any AAC support used to gain consent: This form will be kept in my health notes The therapist gave me a copy (please tick)  Another copy will be kept by the Speech & Language Therapy Service