PHOTO CONSENT FORM

Patient: ____________________________________________

Address: ____________________________________________

I hereby grant DR. R. THIND permission to photograph / film / video tape me before during and after the above-mentioned procedure. I understand that the photographs / film / videotape are the property of the photographer. I authorize my photos to be used for Internet and advertising.

I consent to sending of tissues removed to an outside laboratory for histological examination if so deemed by DR. R. THIND.

I also specifically authorize the above named physician or his assistants, to perform such additional procedures or render such treatment as deemed necessary in his professional judgement in the event that any unforeseen condition arises which would jeopardize my health during the course of, or after, the consented operation.

I certify that I have read the fully understand the above form, that the explanations there in referred to were made and that all blanks or statements requiring insertion or completion were filled in and inapplicable paragraphs, if any were stricken before I signed.

I GIVE MY CONSENT TO HAVE THE ABOVE MENTIONED PROCEDURE(S) PERFORMED UNDER THE ABOVE MENTIONED CONDITIONS.

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Signature of Patient

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Signature of Witness

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Date/Month/Year

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Signature of Physician