This authorization grants permission to use your image in perpetuity for clinical documentation and educational purposes.

By signing this document, you agree:

    1.   To allow the recording of your image (e.g. photographs, via DermCam or similar method), to be stored
          in your electronic chart.
    2.   To distribute and display your image in any medium, for the purpose of clinical documentation and
          education. However, the images will never be transmitted by fax or posted on the Internet.
    3.   To grant permission to other entities to reproduce the images for educational purposes, in which case
          your anonymity will be assured through all reasonable means.
    4.   That there is no reimbursement for the right to take, or to use your photograph or recording.