Photographic Consent and Release

Photographic Consent and Release - Jose Barrera MD

Name
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Endormir Sleep & Sinus Institute
Texas Center for Facial Plastic and Laser Surgery

PHOTOGRAPHIC CONSENT AND RELEASE

I authorize Dr. Jose Barrera, MD, his agent(s), associates, employee(s) or any entity in which he has equity or a professional relationship to use and disclose my images and associated aspects of my care as described below to other healthcare providers, prospective patients, or to general public.

This authorization for release of information covers all past, present and future periods.

I authorize Dr. Jose Barrera, MD his agent(s) associates or any entity in which he may have employment, equity or a professional relationship to photograph and use any images of me including "before" and "after" photos as well as intraoperative photos as well as intraoperative photos. These images may be used for, but not limited to, academic presentations, publications, or advertising which may include posting my images on the internet or social media, where I understand that it would not be possible to remove or delete them. I understand that in some circumstances the photographs may portray features, such as my face or distinguishing mark, that may make my identity recognizable and waive the opportunity to review any images prior to release. I also authorize the release of my conditions, diagnosis, and procedural details relevant to the images.

This authorization shall be in force and effect indefinitely unless I revoke it in writing. I understand that I have the right to revoke this authorization, in writing, at any time. However, I understand that it may be possible for Dr. Barrera, his associates or agents to remove or delete images used "online". I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected.

I release and discharge Dr. Barrera, his associates and agents, from all rights that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of photographs.

I understand that my treatment, payment, enrollment, career, or eligibility for benefits will not be conditioned on whether I sign this authorization. I sign without any feeling or coercion or duress and have read and fully understand the above.
Patient Signature *
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E-Signature Field
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Patient Signature Date *
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dd-MMM-yyyy
For Minors under 18 years old: I have read the above Consent and Release. I am the parent, guardian, or conservator of the patient, a minor. I am authorized to sign this consent on his/her behalf and grant this consent.
Would you like to Share your photos for educational and marketing purposes? *
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Yes
No
Patient Signature *
N/A

E-Signature Field
Clear
Patient Signature Date *
N/A

dd-MMM-yyyy

Photographic Consent and Release - Jose Barrera MD

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