I consent for medical imaging (photo, video, and/or audio) to be made of me. I understand that the information may be used in my medical record, for purposes of medical teaching by Laura M. Periman, MD, or for publication in medical textbooks or journals as I have designated below. By consenting to this medical photography I understand that I will not receive payment from any party. Refusal to consent
to photographs, video, and/or audio recording will in no way affect the medical care I will receive.
If I have any questions or wish to withdraw my consent in the future I may contact the staff at Periman Eye Institute. concierge@perimaneyeinstitue.com
By signing this form below, I confirm that this consent form has been explained to me in terms which I understand.