Photo Consent Form

By signing this form, I am authorizing SHarper Plastic and Reconstructive Surgery to use and disclose my medical information on the SHarper Plastic and Reconstructive Surgery website and social media sites such as YouTube, Facebook, and Twitter for the specific purpose of informing the general public about plastic surgery and plastic surgery procedures and techniques.

INFORMATION TO BE RELEASED: Medical Photographs, Slides, and/or Video Footage

For the following Date(s):

through to

HOW THIS FORM MAY AFFECT ME AND MY RIGHTS

Right to Revoke Authorization. I understand that I have the right to revoke this authorization, except to the extent that SHarper Plastic and Reconstructive Surgery has already used or disclosed my medical information in reliance of this authorization. I understand that my revocation is effective only if it is in writing. To revoke my authorization, I understand that I must send a written request for revocation to SHarper Plastic and Reconstructive Surgery medical records staff.

My Medical Information May Be Re-Disclosed. I understand that if my medical information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by a person who receives my medical information. I understand that this re-disclosure may not be protected by the applicable privacy laws.

Right to Inspect and Copy My Medical Information. I understand that I have the right to inspect and copy my medical information in SHarper Plastic and Reconstructive Surgery records. I understand that to inspect and copy medical information, I must submit my request in writing to SHarper Plastic and Reconstructive Surgery medical records staff. If I request a copy of the information, I understand that SHarper Plastic and Reconstructive Surgery may charge a reasonable cost-based fee in accordance with applicable law to fulfill my request. I understand that SHarper Plastic and Reconstructive Surgery may deny my request to inspect and copy in certain very limited circumstances. If I am denied access to medical information, I may request that the denial be reviewed in certain circumstances.

I Am Not Required to Sign this Authorization. I understand that I may refuse to sign this authorization without affecting my ability to obtain treatment at SHarper Plastic and Reconstructive Surgery. However, I also acknowledge that I have agreed to sign this authorization.

Right to Receive Copy of This Authorization. I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form.

EXPIRATION DATE

This authorization will remain in effect for 10 years from the date the authorization is signed unless revoked by me in writing before that date.

Privacy Policy | Terms Of Service