DIVERSITY IN IMAGERY PROJECT

DIVERSITY IN IMAGERY PROJECT

Release Form
This form seeks for the consent for images to be taken by the Icahn School of Medicine at Mount Sinai through a project representative.

By signing this form, you affirm in understanding that the the images may be used for different purposes indicated hereunder. By consenting to the release of images, you agree that you will not receive any form of compensation in cash or in kind.

You likewise understand that your name will not be included in the images. Nonetheless, it is still possible that someone may still recognize you. The captured images will be stored in a HIPAA-compliant database and will only be accessed by authrorized individuals associated with the project.

Your refusal to consent to the release of your images will not, in any way affect the medical care you will receive. You may rescind your authorization to the release of the images by writing us a request at EMAIL
I authorize the use of the captured images for the following:*

Educational purposesOther
Name of Patient
I have read above terms and conditions and hereby authorize to release the images.
Signature of Person Providing Consent*

Clear
Date Signed*

MonthDayYear
DateHourMinutesAM/PM Option
Browse Files
UPLOAD IMAGE Cancelof
Image Description (include age, sex, self-identified ancestry/ethnicity)*
Metadata Tag 1
Metadata Tag 2
Metadata Tag 3
Upon submitting this form, you affirm that all your responsibilities and rights have been explained to you.
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