Mr. Shailesh Vadodaria
Unit 3, The Exchange
PATIENT PHOTOGRAPHIC AUTHORISATION AND RELEASE
I consent to the taking of photographs by Medical Arts For Cosmetic Surgery (MACS), Mr. Shailesh Vadodaria or his designee, of me or parts of my body in connection with the plastic surgery procedure (s) to be performed by Mr. Vadodaria.
I have been fully informed that such photographs may be published in any print, visual or electronic media, specifically including, but not limited to, medical journals, textbooks, and the internet website of MACS. I freely consent for such photographs to be published for the purpose of informing the medical profession or the general public about the plastic surgery methods that are employed by Mr. Vadodaria.
I understand that I am entitled to withdraw my consent for the publication or any photographs at any stage I choose.
I waive any right to an payment in connection with distribution or publication of the photographs.
I grant that this consent as a voluntary contribution in the interest of public information in the form of “BEFORE AND AFTER” views of the plastic surgery procedures and certify that I have read the above Authorisation and Release fully understand its terms.
Patient’s signature over printed name
Witness/ Surgeon’s signature over printed Name
I hereby give permission to MACS/ Mr. Vadodaria to use my photographs for the following uses:
Practice photograph album, showing pre and post operative photographs [Yes/No]
Practice website, showing pre and post operative photographs [Yes/No]
I am happy to talk to journalists regarding my surgery [Yes/No]
I would like to do some publicity following my operation/procedure [Yes/No]
Please note that should you agree to talk to a journalist, or do some other publicity, we could always contact you prior to releasing our contract details.
Patients signature over printed name
Witness/ Surgeons signature over printed name.