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Informed Consent for Patient Computer Imaging




AND AUTHORIZATION FOR RELEASE AND USE OF PHOTOGRAPHS


In the course of consultation and discussions with certified medical professionals, I may have been shown, or may be shown or provided certain brochures, pictures of actual patients or pictures on an electronic computer imaging device. I do understand that those pictures and alteration of these pictures seen are solely for the purpose of illustration, discussion, and to provide improved communication with medical professionals. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant differences in how living tissues react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result. Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow improved communication with the medical staff.

I certify my understanding that there is no warranty, expressed or suggested, as to my own final appearance after elective surgery by the use of these electronically altered images.

I hereby grant permission and the unrestricted right for the use of any illustrations, photographs or imaging records created in my case for general information, education, public relations purposes, use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.

I acknowledge that I relinquish all rights, title, and interest in these photographs and/or images, or any right to profit or gain directly or indirectly realized through the use of the photographs/images.

I further certify that this consent can only be revoked in writing and delivered to the physician and will not automatically expire or be revoked by implication. Such revocation shall thereafter be effective as to any further use not already committed to by the physician. Unless earlier revoked, this authorization will expire on the end of the treating physician’s practice of facial and reconstructive surgery, except there will be no expiration for the purpose of medical or scientific research. Revocation will not affect uses and disclosures made before receipt of the revocation. If the photographs are disclosed, there is obviously potential for re-disclosure some of which would not be subject to this authorization. This authorization is in consideration of services performed and consultations conducted or to be performed or conducted by the physician, and there have been no representations or inducements concerning this authorization except as set forth herein. The treating physician will not condition treatment on whether the individual signs this authorization, but, if any portion of the treating physician’s services is to be covered under any insurance or third-party payment plan, the signing individual will be responsible for authorizing release as required by that insurance or third-party payment plan.

Electronic Signature *

Date




AUTHORIZATION BY PARENT OR GUARDIAN

Electronic Signature of Parent/Guardian

Date