Breast Augmentation Fat Transfer Photo Consent Form
Consent for clinical photography and limited educational use related to breast augmentation with fat transfer.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Procedure Confirmation
*
I am scheduled for breast augmentation with fat transfer
Purpose of Clinical Photos
*
Treatment documentation
Internal medical records
Educational purposes (with consent)
Photo Identification Preference
*
Photos may be used with identifying features obscured (face, tattoos, etc.)
Photos may be used without identifying features
I understand that my participation in clinical photography is voluntary and does not affect my care.
*
I understand and agree
Signature
*
Submit Consent
Submit Consent
Should be Empty: