BRADLEY K. BECKER - Cosmetic Surgery, Plastic & Reconstructive Surgery

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

PHOTOGRAPHY CONSENT

I consent to the taking of photographs or video by Dr. Bradley K. Becker, associates or representatives of myself or parts of my body in connection with the procedure/surgery intended to be performed. I understand that photographs may be taken before, during and/or after myprocedure or surgery as a routine part of my medical care and that all photographs or video will be kept strictly confidential.


RELEASE OF PHOTOGRAPHS CONSENT

I authorize the use of my photographs or video in the formats listed below. I waive any right to inspect or approve the finish product, advertising or other copy that may be used in connection with the option below. understand that I will be identified by name in any use of these photographs or video, but that in some circumstances they may portray features which me make my identity recognizable.

Please initial or check YES or No for each item below:

I release and discharge Dr. Bradley K. Becker, associates and representatives from all rights and may have in the photographs or video and from any claim I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of photographs or video. This consent may be revoked at any with written consent.

I certify that I have read the above Authorization and Release and fully understand its terms.

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