Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Parkinson’s Disease Research, Education and Clinical Centers

Quick Links

Veterans Crisis Line Badge
My healthevet badge

Consent for Photography

 

NAME:_____________________________________________________________

I hereby authorize _______________________________________________and their colleagues to make video recording and/or photographs of me while undergoing medical and neurological testing and surgery.

The purpose of these recordings/photographs is to document my medical and neurological function prior to, during and following treatment for my medical condition.

While these recording/photographs may be used for teaching purposes, they will not be shown to the public or to the media without my express consent.

I have read and understand the foregoing and I consent to the use of my picture and voice as specified above.

 

_____________________________________ _________________________
Signature of Patient                                                 Date

_____________________________________ __________________________
Signature of Interviewer                                           Date