2. CONSENT FOR USE/ RELEASE OF PHOTOGRAGHS/ SLIDES/ VIDEOS
I hereby authorize Coolspa, David P. Rapaport, M.D., F.A.C.S., and any of its Associates/Providers to use pre-operative, intra-operative photographs & post-operative slides, and/ or videos for:
I. Professional medical purposes including but not limited to showing these images during lectures to medical groups and printing in professional medical journals.
II. Patient education including showing images anonymously to other potential patients/ lay persons.
III. Other purposes deemed appropriate by my physician including but not limited to showing images on public or commercial media, electronic digital and on-line networks, lay or commercial publications.
I understand that I will not be entitled to monetary payment or any other consideration as a result of any of these images and/ or my interview.