NOTE: This form is NOT required for photos or videos of patients used for the purposes of treatment or diagnosis, where the photo and/or video becomes part of the patient’s medical record and is not used for any other purpose.
I authorize the Women's Health Specialists ("WHSFL") to take photographs and/or videos, or to allow third parties to take photographs and/or videos, or to use photographs and/or videos provided by the above named subject, for the following uses:
I understand that:
I may revoke this Authorization at any time:
- the revocation will not apply to information that has already been released in response to this Authorization.
I may refuse to sign this Authorization:
- WHSFL will not condition my treatment, any payment, enrollment in a health plan, or eligibility for benefits on receiving my signature on this Authorization.
I have been informed and understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected by federal and state privacy laws.
Upload any photos that you would like for us to feature.
Accepted file types: jpg, jpeg, webp, Max. file size: 4 MB, Max. files: 5.
Drop files here or
By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.