May be taken before, during or after any surgical procedure or treatment.
Consent is required to take such images.
1. Consent to take photographs/slides/video tapes
I hereby authorize Dr. Miguel L. Gallegos M.D. and his associates or licensees to take pre-operative, intra-operative, and post-operative photographs.
2. Consent for release of photographs/slides/video tapes
I hereby authorize Dr. Miguel L. Gallegos M.D. and his associates or licensees to use pre-operative, intra-operative, and post-operative photographs or video tapes for professional medical purposes deemed appropriate for medical education, patient education, lay publication or during lectures to medical lay groups.
I understand that I will not be entitled to monetary payment or any other consideration as a result of any use of these images and/ or my interview.