I authorize the taking of clinical photographs for my medical record, to be used for scientific purposes both in publication and presentations. I understand my identity will be protected.
I release Lenox Laser and Esthetics medical staff from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.