I hereby give consent and authorization and voluntarily release, NOVA Derm Institute from claims, implied or stated that I have, or may have in future with this treatment, regardless of the result. I am stating that, my treatment and precautions above have been explained to me in detail, and all the health and medication use info I provided is correct and complete.
I, voluntarily consent to the Copyright, publication, and use of my picture and likeness by NOVA DERM INSTITUTE, affiliates, successors, and assignees. By signing this form, I am allowing, NOVA DERM INSTITUTE affiliates, successors and assignee to disclose photographs taken of me before, during, and after treatment.
(Please choose either yes or no on each line)
I hereby release from NOVA DERM INSTITUTE any claim, demand, cause, action, or proceeding of whatever nature arising out of publication and distribution of the said photographs in accordance with the terms of this release. This release also includes affiliates, successors, and assignees of. I also understand that I can revoke (or take away my permission to allow to disclose photographs of me at any time by sending a letter to Nova Derm Institute Medical Director telling him or her not to disclose photographs of me to affiliates, successors, or assignees of Nova Derm Institute. If I send a letter saying that I revoke my authorization, Nova Derm Institute’s Medical Director will not disclose any more photographs of me after he or she receives the letter. However, the Medical Director will not need to return any photographs disclosed prior to his or her receipt of the letter.
I understand that once my photographs have been disclosed to NOVA DERM INSTUTUTE, affiliates, successors and assignees the photographs will no longer be protected by federal privacy laws. However, NOVA DERM INSTITUTE’S affiliates, successors, and assignees will not use the photographs except as permitted on this authorization form. I understand that I will be given a signed copy of this form.
I hereby release NOVA DERM INSTITUTE, its affiliates, successors, and assignees from any claim demand, cause, action, or proceeding of whatever nature arising out of publication and distribution of the said photographs in accordance with the terms of this authorization.