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