cornell university · web viewthe sean parker institute for the voicetelephone: +1 (646) 962-2226...

Babak Sadoughi, MD 1305 York Avenue, 5th FloorNew York, NY 10021

Assistant Professor of Otolaryngology – Head & Neck SurgeryThe Sean Parker Institute for the Voice Telephone: +1 (646) 962-2226Department of Otolaryngology – Head & Neck Surgery Direct Line to Practice Coordinator: +1 (646) 962-4712 Weill Cornell Medical College-NewYork Presbyterian Hospital Facsimile: +1 (646) 962-0384

Email: bas9049@med.cornell.edu Authorization for Photography

In the course of consultation for treatment, I understand that it may be necessary to have photographs and video images taken, I hereby give permission to Dr. Babak Sadoughi to take photographs and video images of me for diagnostic purposes and to enhance the medical record. I agree that these photographs will remain his property unless otherwise indicated.

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I also acknowledge that facial images altered by morphing software are for educational purposes only. The complexities and individual variations in the healing process can alter a surgical result therefore it is impossible to predict with perfect accuracy, preoperatively, a final surgical result. The morphed images in no way imply a guarantee of a surgical result.

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Occasionally, Dr. Sadoughi may find it beneficial to use photographs or video images outside of your medical record. When this occurs, it is understood that, for any use, you shall not be identified by name. In any case, this cannot be done without your permission. Please initial if you authorize Dr. Sadoughi to utilize your pictures in the manner stated.

____________ I allow Dr. Sadoughi to utilize my photographs for the purpose of educating other medical professionals (i.e.—in lectures).

____________ I allow Dr. Sadoughi to utilize my photographs in scientific journals and publications.

____________ I allow Dr. Sadoughi to utilize my photographs for his webpage.

____________ I allow Dr. Sadoughi to utilize my photographs for the purpose of marketing and advertising (i.e.—in brochures, etc.).

Signature Patient/Guardian Name (printed) Date