I give consent that Refine Aesthetics can photograph or film me but only to the extent necessary and so long as the images are used solely for purposes of (a) identifying me as a patient or for purposes of documenting my health status, diagnosis and treatment while a patient; (b) conducting education and training, quality assurance and performance improvement functions for and on behalf of Refine Aesthetics and its professional staff; and (c) publishing the results of my treatment on Refine Aesthetics's website which, in this particular case, required me to sign the HIPAA authorization form.

The purpose of this form is to obtain my prior written consent so that Refine Aesthetics may photograph or film me for one or more of the following purposes listed below for which I do hereby consent.

Use or disclosure of image for marketing or advertising purposes and patient education Use or disclosure of image for medical specialty board in formulating its examination of applicant physicians Use or disclosure of image in a professional presentation or journal publication Unless earlier revoked, this authorization will expire on the end of the treating physician's practice of surgery, except there will be no expiration for the purpose of medical or scientific research or use in specialty board examinations.

I also agree to sign the HIPAA authorization form which permits Refine Aesthetics to use or disclosure these images but only to the extent permitted by HIPAA and other applicable laws and regulations. Computer Imaging Disclaimer Computer imaging may be used to better educate you about your upcoming surgery. Although an approximation of intended results is to be displayed, I realize that there are differences in graphic artistic ability and surgical technique. I realize that computer imaging does not constitute and should not be construed to be an exact representation of post-surgical results. I understand that it is impossible to guarantee intended results. I understand that the alteration of any images is purely for the purpose of education, illustration and discussion.