agree that Beautologie Medical Group, Inc, Drs. Darshan Shah, Milan Shah, Brett Lehocky, James Knoetgen or designated representatives or the practice may take and use preoperative and postoperative photographs of my person for confidential clinical record purposes, and that such photographs shall remain the property of Beautologie Medical Group, Inc, Drs. Darshan Shah, Milan Shah, Brett Lehocky, or James Knoetgen.
I fully and specifically grant my permission for the use of photographs, videotapes or case information for the following purposes as indicated by my initials below. As a result of this use I understand that these photographs, videotapes or case information may appear in other related, updated or reprinted formats at any concurrent or future occasion. I understand that such consent is strictly on a voluntary basis. I understand a copy of this consent may be supplied with the images to any third party wherein they may be published or presented. Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the photographs may portray features which shall make my identity recognizable. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I understand that I have the right to revoke this authorization in writing at any time, but if I do so it won't have any effect on any actions taken prior to my revocation. If I do not revoke this authorization, it will expire twenty years from the date written below. I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from Beautologie Medical Group, Inc, Drs. Darshan Shah, Milan Shah, Brett Lehocky, or James Knoetgen. I authorize Beautologie Medical Group, Inc, Drs. Darshan Shah, Milan Shah, Brett Lehocky, or James Knoetgen to use my photographs, videotapes, and case information in the following educational and scientific settings that I have initialed:
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Use in professional publications such as textbooks, journal articles, educational videos or magazines (the Work) that Beautologie Medical Group, Inc, Drs. Darshan Shah, Milan Shah, Brett Lehocky, or James Knoetgen may publish in the future for patient or professional education. This may include printed versions or other media. The undersigned authorizes the specific publisher of the Work and its affiliates and its licensees to reproduce photographs taken or used in connection with all editions of the textbook, journal article or magazine. Such photos may be published, reproduced, exhibited, copyrighted, and used in and published anywhere in the world in connection with all editions of the Work and other works of the publisher, in any manner whatsoever (including advertising related solely to promotion of such editions of the Work) without further consent from or payment to the undersigned who hereby forever releases and discharges the publisher, their employees, licensees, agents, successors, and assigns from any claims, actions, damages, or demands whatsoever by reason of any such use
I understand that such photographs, videotapes or case histories may be published by Beautologie Medical Group, Inc, Drs. Darshan Shah, Milan Shah, Brett Lehocky, James Knoetgen and/or the American Society of Plastic Surgery (ASPS) or the American Society for Aesthetic Plastic Surgery (ASAPS) and/or any party acting under their license and authority in any print, visual or electronic media including, but not limited to, medical journals and textbooks, scientific presentations and teaching courses, books, magazines, and internet websites, for the commercial, non-profit and/or educational purpose of informing the medical profession or the public about plastic surgery methods.
I understand that the information disclosed, or some portion thereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). I further understand that, because ASPS or ASAPS is not receiving the information in the capacity of a health care provider or health plan covered by HIPAA, the information described above may no longer be protected by HIPAA.
I release and discharge Beautologie Medical Group, Inc, Drs. Darshan Shah, Milan Shah, Brett Lehocky, James Knoetgen, ASPS, ASAPS, and all parties acting under their license and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photographs.
I grant this consent as a voluntary contribution in the interest of public education and certify that I have read the above. Authorization and Release and fully understand its terms.
I have read the above Authorization and Release.
I am the parent, guardian, or conservator of,