Name: Tampa Bay Cosmetic Surgery Center
Telephone: +1-(727) 522-3223
Price range: $$

PHOTOGRAPHIC CONSENT FORM FOR MEDICAL RECORDS

I authorize my physician, Dr. Lawrence G. Kass, or any of his designated assistants, to take photographs of me at any point in my medical management as is considered necessary for my medical records. These photographic records are generally required by insurance companies for their documentation and processing of claims.
Name*
First Last
Signature of patient/guardian*
Date*
MM slash DD slash YYYY
Witness signature*
Date*
MM slash DD slash YYYY
PHOTOGRAPHIC CONSENT FORM FOR USE OF PATIENT PHOTOS IN MEDICAL RESEARCH, MARKETING, OR EDUCATIONAL PURPOSES

If the physician feels the photographs are beneficial to medical research, marketing or education, such photographs, and related information may be published and republished in professional journals, medical books, or used for other purposes for allied medical personnel and lay persons. Identifying features may be visible, but the patient’s name or personnel information will be held in anonymity in any publication.
Photograph consent:
- I authorize the use of photographs for medical research, marketing, or educational purposes.
- I DO NOT authorize the use of photographs for medical research, marketing, or educational purposes.
Signature of patient/guardian*
Date*
MM slash DD slash YYYY
Witness signature*
Date*
MM slash DD slash YYYY
CAPTCHA

Photographic Consent Form