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.

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Signature of Patient                                                 Date

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Signature of Interviewer                                           Date