Patient Consent for Medical Photography

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I consent for medical imaging (photo/video and/or audio) to be made of my eyes. I understand that the information may be used in my medical record, for purposes of medical teaching by Jennifer Shaba Yalldo O.D., or for publication in medical textbooks or journals as I have designated below. By consenting to this medical photography, I understand that I will not receive payment from any party.

Refusal to consent to photographs, video and/or audio recording will in no way affect the medical care I will receive. If I have any questions or wish to withdraw my consent in the future, I may contact the staff at Dry Eye Healing Institute. MiDryEye@gmail.com

By signing this form below, I confirm that this consent form has been explained to me in terms which I understand.

Name *

Date of Birth *

YYYY

Please indicate one of the following: *

I consent for these photographs to be used in medical publications, including clinical trials, medical journals, textbooks, and electronic publications. I understand that the image may be seen by members of the general public, in addition to scientists and medical researchers that regularly use these puublications in their professional education. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also agree for my image to be shown for teaching purposes by Jennifer Shaba Yalldo, OD.

I agree for my image to be shown for teaching purposes AND to be used for my medical record but NOT for medical publication.

I agree to the use of my image for medical records ONLY.

Patient Signature: *

Date of Consent *

YYYY

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