By signing below, I hereby represent and warrant that I am age 18 or older (or if I am under 18 years old, then my parent or legal guardian warrants and represents and gives permission on my behalf), that my participation is voluntary and that I am voluntarily agreeing to and consenting to receive certain medical and other procedures while being photographed and/or filmed. In connection with medical services I am receiving from my physician, David Allison MD, by signing below I consent that photographs, surgical videos, and postoperative testimonial videos may be taken of me or appropriate parts of my body. The photographs and surgical videos may be taken only with the consent of my physician and only under such times and conditions as approved by her. The photographs and surgical videos shall be taken by my physician or by a photographer approved by my physician. My name, voice and/or sound and testimonials may be used in conjunction.

I hereby grant Becker Nose and Sinus Center LLC, doing business as David W. Allison, MD, Becker Plastic Surgery and other dba names, the absolute right and permission to copyright and/or use, re-use and/or publish, and/or republish photographic, film and video images of me, my voice and/or sound performance and testimonials in any scenes in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations from time to time body under the following conditions:

1. The photographs and surgical videos may be used for my medical records.
2. If in the judgment of my physician, medical research, science, or education including patient education will be benefitted by their use, such photographs and video and information relating to my case may be published and republished without restriction and without compensation, either separately or in connection with each other, in professional journals or medical textbooks, including online journals and medical books, or used for any other purpose that she may deem proper in the interest of medical education, knowledge or research; provided, however, that it is specifically understood that in any such publication or use I shall not be identified by name.
3. The photographs and surgical videos may be used by Becker Nose and Sinus Center LLC, doing business as David W. Allison, MD, Becker Plastic Surgery and other dba names without restriction and without compensation on their associated Websites, Instagram and other Social Media, and on the Internet; provided, however, that in any such use I shall not be identified by name.

I hereby waive any right that I may have to inspect and/or approve applicable promotional use of the following: (1) the finished product or products; (2) the advertising copy; and (3) printed material.

I hereby represent and warrant that I am of full age and have every right to contract in my own name with respect to the aforementioned provisions. Further, I warrant that I have read and understand the aforementioned authorization, release and agreement, prior to its execution, and that I am fully familiar with the contents thereof.