• Authorization for Photo/Media Release to Kapolei Eye Care

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  • I consent to photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and educational purposes. Although the photographs or accompaning material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.

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  • If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.

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