Revised Patient Photographic Authorization & Release
Plastic and Reconstructive Surgery. Rod J. Rohrich, M.D., Editor. ... _____ or his designee of me or of my likeness or parts of my body in connection with the following plastic surgery procedures(s) _____ to be performed by Dr. _____ on (Date) and (Location). ... guardian or conservator of _____, a minor. I am authorized to sign this consent on ... ................
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