10/08

KENNEDY SLEEP CENTER

AUTHORIZATION TO PHOTOGRAPH AND/OR VIDEOTAPE

FOR MEDICAL PURPOSES

PATIENT NAME: __________________________________________ AGE: __________ (PRINT: First, Middle, Last)

Select #1, #2, or #3 in Part A below by placing an “X” in the appropriate box. Read Part B before signing in the presence of a witness. PART A 1) I am the patient named above in the Kennedy Sleep Center 2) I am the parent or legal guardian of the patient named above 3) I am not the parent or legal guardian of the patient named above, but I have the following relationship to the patient:

Note: If #3, above is checked, immediate Administrative notification is required. PART B I hereby authorize Dr. ________________ and such assistants, photographer, technicians and other persons as he or she may engage for this purpose to take such photographs and/or videotapes of me as he or she may desire relating to any medical treatment that I may receive on or about _____________________ at Kennedy Sleep Center and to be used for any other purpose that he or she may deem fit in the interest of my own medical care. I also authorize Kennedy Sleep Center to permit such photographing and/or videotaping. I acknowledge that I will receive no compensation, whatsoever, from any party. SIGNATURE ______________________________________ DATE: ______________ PRINT NAME: ____________________________________ TIME: __________AM/PM WITNESS: ________________________________________ DATE: ______________