Authorization for Use of Image

Patient Alias:

Consent Validity:

Media:
Photographs;
Videotape images;
Audiotape;
Film/Movie/Slides;
Other:

Purposes:
Identification;
Training;
Media Coverage;
Research;
Other:

Audience:
Staff/Students/Volunteers;
Public;
Other:

I provided the individual with a copy of this form in:
English;
Spanish;
Other: