Authorization for and release of medical photographs/slides/videotapes:

It is necessary that medical photographs may be taken before, during, and after a procedure, or a treatment. Similar to other imaging techniques, this allows for proper planning before procedures and follow-up evaluation afterward. Photographs are required only for the body part in question. This means that unless the plant treatment is on the face or head itself, the images typically do not include the face. Consent is required to take such images. Additionally, patients may consent to the release of these medical photographs, slides, and videotapes for a stated, purpose, such as for use in instructional, educational, or promotional materials. These materials are very important to ensure a continued understanding of the treatments available to all patients. Please read carefully the information contained in both sections below, and provide your consent, where applicable.

Signature in sectional is required to receive your care at Aesthetics+ MD, however, your signature in section 2, while encouraged, is optional.

Section 1: Consent to take photographs and videotapes. I hereby authorize Dr. Shah, medical Director of Aesthetics Plus MD, LLC, and, or her associates to take pre-procedural, procedural, and post-procedural photographs and/or videotapes. I consent to the use of these images for the purposes of pre-procedural planning and post procedural evaluation. I understand that they shall be made a part of my medical record.

Section 2: Consent for the release of photographs and videotapes. I hear by authorized Dr. Shah, medical Director of Aesthetics Plus MD, LLC, and her associates to use pre-procedure, procedural, and post procedural photographs and/or video tapes for professional, medical or promotional purposes. This includes but not limited to display of these images on public or commercial television, electronic digital networks, scientific medical publications, lay publications, or during lectures to medical or lay groups for the purposes of informing the medical community, or the general public about treatments and procedures available at Aesthetics Plus MD, LLC. Neither I nor any member of my family will be identified by name at any time. Unless it is necessary to include it, my face will not appear in the images. I understand that in some instances, the images may portray features which could make my identity recognizable. I understand that I will not be entitled to monetary payment or any other consideration as a result of any use of these images. I hereby grant this consent as a voluntary contribution in the interest of medical education. This permission may be rescinded by me at any time to prohibit future use by direct written communication with Dr. Shah or Aesthetics Plus MD, LLC.