Mojo Cosmetic Clinic Medical Photography and Media Release Consent Form

Patient Name:

Date of Birth:

Medical Photography Consent:

I understand that medical photos may be taken for storage on my medical record, teaching, and/or publication. Refusal to consent will not affect my medical care. If I have questions or wish to withdraw consent, I may contact Dr Maria Mackey.

Consent Options:

I CONSENT to the storage of my image/s in my medical record.

I CONSENT for my image/s to be shown for teaching purposes. I understand that these images may be seen by medical professionals.

I CONSENT for my image/s to be shown to other patients for illustration purposes.

I CONSENT for my image/s to be used in medical publications.

I DO NOT CONSENT to have medical photographs taken.

Media Release Consent:

I, give my permission for Mojo Klinik to utilize information, photographs, and video regarding my treatment to be released to the following media platforms:

Consent Options:

I consent to using my photographs and videos as they are.

I prefer no distinguishing features to be shown. Where full facial shots are used, my eyes are to be blacked out.