Energist UltraPlus VPL™ System
User Manual
SD1-43 Issue 3 (CCF 296)
103
Photo Consent Form
I, the undersigned, hereby give the treatment facility and its clients or agents
permission for use of photographs taken of me, provided reasonable measures are
taken to protect my identity. I understand these photographs may be used for either
teaching or publication purposes and may include:
1.
To copyright the same in their name or any other name they choose.
2.
To use and publish the same in whole or in part, individually or in conjunction
with other photographs, in any medium for any purpose including medical
records, professional journals, medical textbook, art, illustration, promotion,
advertising or trade.
3.
It is understood that the use of the photographs is for illustrating cosmetic
procedures and demonstration of benefits. It is also understood that the use of
the photographs will in no way reveal patient identity.
4.
The aforementioned photographs may be modified at the discretion of the
facility, its clients, or agents to be more desirable. This would include, but
would not be limited to, masking of the photographs to prevent identification
or to cover private parts of the body.
I hereby release ________________________________(the facility, its clients and
agents) from any and all claims and demands arising out of or in connection with the
use of the photographs.
I am of legal age.
I have read the foregoing document and fully understand its contents.
Name:
Address:
Tel:
Date:
Signature:
Parent/Guardian:
Witness:
Area(s) photographed:
