Patient Computer Imaging

In the course of consultation and discussion with Dr. Prysi, I may have been shown or may be shown or provided certain brochures, and/or pictures on an electronic computer imaging device. I understand that those pictures and alteration of those pictures seen are solely for the purpose of illustration/discussion and to provide improved communication with the doctor. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant differences in how living tissues react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result.

Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow an improved communication with the doctor.

(Please initial 1 of the following)

I hereby DO grant permission for the use of any illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.

I hereby DO NOT grant permission for the use of any illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.

I certify my understanding that there is NO WARRANTY, expressed or suggested, as to my own final appearance after elective surgery by the use of these electronically altered images.