KEC Photo/Media Release Consent

Authorization for Photo/Media Release to Kapolei Eye Care
Patient's Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
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.
I allow Nancy Chen, M.D. and Kapolei Eye Care to use my photographs and other media:

I DO I DO NOT
Patient's Signature *

Clear
Date *

Month Day Year
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First Name Last Name
Relationship to Patient
Should be Empty:

Authorization for Photo/Media Release to Kapolei Eye Care