| Right to revoke: you will have the right to revoke this consent at any time giving us written notice of your revocation submitted to the Contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.|
I, , have had full opportunity to read and consider the contents of this consent form and your Notice of privacy practices. I understand that, by signing this consent form. I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
| X I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers or demonstrations.|