Online Photography Consent Form

ONLINE PHOTOGRAHPY CONSENT FORM
I, the undersigned, hereby authorize Surface Clinical to take my pre-photos for planning purposes, medical evaluation, surgical or other procedures and subsequent treatment.Your photos will not be used in any publication or on the Internet without your notification and a separate form signed by you. I herein relinquish any right, title, or interest in such photographs and I understand that my identity will not be revealed by the pictures or by the descriptive texts accompanying them.

Person Photographed:
First and Last Name:*
Email*
Phone*
Date*
Date Format: MM slash DD slash YYYY
Signature*
Requested by: Surface Clinical
4311 Oak Lawn Avenue, Ste. 380
Dallas, Texas 75219
214-821-9355

ONLINE PHOTOGRAHPY CONSENT FORM