I hereby authorize Dr. Vaziri and Staff to take clinical photographs, videos, or digital images of my condition, both before and after treatment. These images may be presented to scientific, medical, dental and similar groups, including local advertisement publications and/or printed journals and publications for teachings or educations purposes including our internet web site. Although the images will not be labeled with my full name, I am aware that certain images may reveal my identity.

All images remain the property of Dr. Vaziri and may be used in the future unless I specifically notify Dr. Vaziri and/or staff in writing that I do not wish the images to be shown.

The undersigned hereby waives any rights to compensation for such uses by reason of the foregoing authorizations, and the undersigned and his successors and assigns harmless from and against any claim for injury or compensation resulting from the activities authorized by the agreement.

I would also be willing to discuss my experiences with other patients or interviewers if contacted.

The term “photograph” as used in the forgoing agreement, shall mean motion picture or still photography in any format, as well as videotape, videodisc, and/or any other mechanical means of recording and reproducing images.