By signing this form, I, the above mentioned Patient, authorize my physician and staff representatives, to take photographs of my body for medical purposes to be used for my patient care, marketing, literature and/or case presentations.
I understand that:
» Photographs are taken to capture treatment outcomes for my procedure.
» They may be used for print, visual or electronic media including but not limited to, scientific presentations, websites and for purposes of informing the medical profession or general public about the procedure. These uses may also include marketing on behalf of the physician’s practice.
» They may be released to ALLERGAN (for Botox & Fillers procedures), and/or ZELTIQ Aesthetics, Inc. (“ZELTIQ”) (for CoolSculpting and CoolTone procedures), and may be used for print, visual or electronic media including but not limited to, scientific presentations, websites, general marketing, and for purposes of informing the medical profession or general public about your procedure.
» The images taken of me may be published by the physician, ALLERGAN, ZELTIQ, and their agents and representatives.
» I will not be identified by name in any of the published materials.
» My face will not be shown in the photographs nor will they reveal my identity.
» I have the right to revoke this authorization in writing at any time through a written revocation to my physician and ALLERGAN and/or ZELTIQ.