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CONSENT AND RELEASE FOR USE OF PHOTOGRAPHS, DIGITAL IMAGES, AND/OR VIDEOTAPES

I hereby authorize Dr. Solieman, Dr. Litner, aided by such assistants, photographers, or technicians as they may engage for this purpose, to take such photographs, digital recordings, and/or videos of me as he may desire at this time and before, during, and after any operation or procedure which is to be performed on me. I further grant these physicians the ongoing and unrestricted right to use the undersigned’s images for general information, education, scientific, medical, and research purposes or for any other purpose which they may deem fit with the understanding that my name will never be used to identify myself. The images may be conveyed or displayed for those purposes through electromechanical means, including the Internet. I hereby give my Profiles Doctor the right and unrestricted permission to use, reproduce, or publish all such images, and I relinquish all right, title, and interest in these images to my Profiles Doctor. I may revoke this consent in writing, delivered to my Profiles Doctor. Such revocation shall therefore be effective as to any further use not already committed to by these physicians. This consent is in consideration of services performed and consultations conducted or to be performed or conducted by my Profiles Doctor. There have been no representations or inducements concerning this consent, except as set forth herein.



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