First Name

M.I.

Last Name

Date of Birth (mm-dd-yyyy)

Consent to medical images and / or video images being made of me or (child, if the
child is the patient) not limited to one date of service. I agree that duplicates
may be made for the referring doctor.

I agree that my images may be:
(Please check yes or no to show type of consent)

I further acknowledge that there were no promises of compensation for such use of my medical photo(s) and/or video taken by Indigo Dermatology as consented above.

This consent may be revoked at any time by the “signing patient” with written consent.

By signing below I confirm that I understand this consent form

Signature

Date

Signature of
SelectPatientParent if MinorLegal Guardian