Patient Consent for Medical Photography

Patient Consent for Medical Photography
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
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.
Please indicate one of the following:*

I consent for these photographs to be used in medical publications, including clinical trials, medical journals, textbooks, and electronic publications. I understand that the image may be seen by members of the general public, in addition to scientists and medical researchers that regularly use these publications in their professional education. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also agree for my image to be shown for teaching purposes by Laura M. Periman, MD.I agree for my image to be shown for teaching purposes AND to be used for my medical record but NOT FOR medical publication.I agree to the use of my image for medical records ONLY.
Signature*

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Name*

First NameLast Name
Date of Consent *

MonthDayYear
Date
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