Dell P. Smith, M.D., F.A.C.S.

Board Certified

Plastic and Reconstructive Surgery

Cosmetic Surgery * Hand Surgery

1880 Fillmore Street

Twin Falls, Idaho, 83301

(208)735-8386 * Fax (208)735-0434

Consent to Taking and Publication of Photographs

Patient’s Name: _________

Date: __________________

In connection with medial services that I am receiving from my physician, Dr. Dell P. Smith, I consent that photographs may be taken of me or parts of my body, under the following conditions:

1. The photographs may be taken only with the consent of my physician and under such conditions and at such time as may be approved by my physician.

2. The photographs shall be taken by my physician or by a photographer approved by my physician.

3. The photographs shall be used for medical records and, at the discretion of my physician, such photographs and information relating to my case may be published and republished, either separately or in connection with each other, in professional journals or medical books, or used for any other purpose including internet use that my physician may deem proper; provided, however, that it is specifically understood that in any such use I shall not be identified by name.

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^{Signature (Patient or legal guardian if patient is a minor)}

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^{Print Name of Patient}

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^{Attest (Witness) Signature}

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^{Attest (Witness) Print Name}