Patient Info

HIPAA Notice of Privacy Practices

Leading Edge Dental
10601 Hwy 441-C1B
Leesburg, Fl 34788
(352)365-6442

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Print Name:__________________________ Signature______________________Date_______

One in four Americans between the ages of 6 and 50 will sustain an injury to their incisors, according to a recent study by the National Institute of Dental Research, so it is important to know how to respond in a dental emergency. The University or Washington's Health Beat reports that the prognosis for patients following a dental injury often depends on the type of injury and the amount of time it takes for a patient to receive treatment following a dental injury.

One of the easiest injuries to treat is a chipped tooth. If the tooth is only slightly chipped, the patient should see a dentist as soon as possible. It is no longer always necessary to use a crown to repair the damage because new filling materials can restore the tooth, "like putting an adhesive bandage on a wound." More severe damage to a tooth may require a root canal and a crown.

If a tooth is knocked out, the patient should immediately replace the tooth in the socket, if possible. The tooth may very well last a lifetime if replaced immediately. If it is not possible to replace the tooth, the patient should place the tooth in milk, saline solution, saliva or tap water to keep it moist, then see a dentist.

Whatever the injury, the patient should have the dentist examine the injury to determine whether the inside of the tooth has been damaged and may require treatment. Moreover, patients should not hesitate to contact a dentist after hours in a dental emergency, because with dental injuries, time often is crucial to effective treatment.

At Leading Edge we are pleased to offer a variety of financial options to you to help it make affordable for the dental services you need without straining your budget.

For your convenience we accept cash, checks, money orders, MasterCard, Visa and we have a program available for qualified patients with regard to extended payment options. We are excited to offer easy financing options that allow you to have 12 -18 months same as cash (no interest) or extended payment options up to 5 years. We recommend the following financing provider because of their easy application and fast approval process. You can apply online at CareCredit or when you visit our office for an appointment where you can apply by phone in just 10 -15 minutes.

Insurance options

Do you accept insurance?

Yes, we work with most insurances providing your plan allows you to go to the dentist of your choosing. We will gladly prepare and send your claims to the carrier for you. Due to the many changes with insurances we are providers of a select few as participating provider plans. Please call our office to discuss your insurance options with us. 352-365-6442

Information about Insurances

Here at, Leading Edge Dental, we want to help you maximize your dental benefits. We will gladly verify and process dental claims to your carrier. We will provide them with any X-rays or written narratives they may need to evaluate the claim for payment. At the time of service we may ask that you pay for treatment performed, and your insurance company will reimburse you according to your plan provisions a few weeks later. We will follow up with your insurance company to be certain you get everything you are entitled to through your policy. Although we may not be participating providers on your insurance plan, most of our patients have dental insurance. If you have regular dental insurance or a PPO you have the freedom to choose who you would like to visit for dental care. The cost difference to visit our practice rather than someone on your list is generally minimal.

Through the years, and our experience with insurance companies, we have noticed that they have constricted their benefits and attached many limitations on what they cover. Although your insurance provider would lead you to believe that your coverage is not complicated, the actual policy guidelines and restrictions are likely 50 pages long. Basically, insurance company executives make decisions without any dental knowledge or regard for your dental needs and only a financial bottom line in mind. Unfortunately, these restrictions tend to dictate the treatment and quality of care we can provide.

Today’s dentistry is nothing like it was 40 years ago or even 10 years ago for that matter. If patients had dental problems, the choices were to extract, fill, or crown the tooth. Today we have many advances, including dental implants, dental lasers, all-porcelain crowns, zirconium-based crowns, cosmetic dentistry, etc. Most insurance companies limit payment to outdated procedures such as metal fillings, metal crowns (without porcelain covering them), and removable partial dentures. Advanced, more conservative restorations like implants, porcelain onlays, and all porcelain crowns have replaced those outdated procedures. The restorations available today are longer lasting and have become the standard of care in my practice. Insurance companies offer little to no reimbursement for these treatments.

When insurance companies attempt to dictate treatment rather than the dentist, the care that patients receive is not ideal, and often ends up with the patient needing more dental treatment in the long run. Insurance companies are very successful and care about one thing: bottom line profits – not what is in your best interest. While we are a business, our main focus is helping our patients achieve and maintain the best dental health possible. I went to dental school to be the best dentist I can be and offer the highest standard of care, so to place a low-cost restoration that I know is not going to last is absurd.

The best approach if you do have insurance is to think of it as a supplement to your treatment and not something that is going to cover any major dental problems. If your insurance is being provided to you through work, then it is a true benefit. However, it will most likely not cover everything you might think it should. If you are paying for your own dental coverage, you might want to look at what you are paying in premiums and actually put that money aside and use it as a dental savings plan a few months premium may cover much of what you need.

Moderate discomfort and swelling occurs with most oral surgery procedures.  They usually begin within the first 12 hours following the surgery and starts to decrease after 48 hours.  The amount of discomfort and swelling is unpredictable.  It is important to take care of your surgery site, so please follow these instructions.

* Bite on gauze for 30 minutes to stop any bleeding.  If bleeding continues, place another gauze and continue to apply pressure.

* For at lease 24 hours DO NOT
1) SMOKE
2) Drink through a straw
3) Drink alcohol, carbonated beverages, or hot liquids
4) Blow your nose
5) Rinse or Spit excessively

Any of these things may cause the blood clot over the surgery to dislodge from  the “socket”, causing a “dry socket” and resulting in unnecessary pain.

*DO maintain a soft diet for the remainder of the day, things like warm soup, ice cream, milk shakes, yogurt, mash potatoes etc.  (Remember NO STRAWS)

* If your discomfort or bleeding continues or worsens call the office for re-examination.

* If you were given medications, take them according to the instructions.  If you have pain medications at home, you can may take them according to the instructions.  Taking your Antibiotics is very important

* Tomorrow morning, start rinsing with warm salt water after eating.

* If any problems or questions arise, please feel free to call the office.

We at Leading Edge Dental are proud to be part of a team whose primary mission is to deliver the finest and most comprehensive dental care services today. We are concerned about your dental care and want to ensure that it is performed in a responsible manner. In order to assist you with your dental health investment, we provide the following options to best meet your needs.

Insurance: We understand the value of insurance benefits and will assist you in maximizing your insurance. We will gladly process your claim at no charge and will also estimate your deductible and your portion not covered by insurance. This is not a guarantee of payment from your insurance company to us it is just an estimate of benefits. The estimated amount not covered by your insurance is due at the time of your treatment and may be paid by one of the options listed below. Remember that if for any reason your insurance company does not pay, you are responsible for the outstanding balance. Also insurance is used as a supplement to help you with you needs not as a full payment plan. I hereby authorize LED to release my dental information to my insurance company.__________. Initials

Initial Payments: We require full payment of the total amount, of the treatment being started, Unless previous financial arrangements have been made.

Payment Options:
1) Cash including checks, and money orders
2) Charge Cards: Visa/MasterCard, Bank Debit (ATM transactions) and Discover
3) Financing options - An open line of credit may be obtained through CareCredit and upon approval can be used immediately. The process takes approximately 15 minutes from start to finish and your work can be started today and the convenience of financing allows you to you spread your costs over a period of time. In the event you decline your treatment after going through the financial process, you will be assessed a fee of 5% of the Total Dollar Amount
Financed.

Please Note: X-rays are the legal property of the office. If your would like a copy for yourself we need a 24 hour notice and a nominal fee of $10.00 for duplicating will be assessed to cover our costs.

Patient:__________________________ Date:__________________________

LEADING EDGE DENTAL ALI VAZIRI, DMD

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information.  “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with a third party.  For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  For example your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment
Your protected health information will be used, as needed to obtain payment for you health care services.  For example, obtaining approval for a hospital stay may be required that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations
We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities.  For example, we may disclose your protected health information to medical school students that see patients at our office.  In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician.  We may also call you by your name in the waiting room when your physician is ready to see you.  We may use or disclose your protected health information, as necessary, to contact you for your appointment.

We may use or disclose your protected health information in the following situations without your authorization.  These situations include: as Required By Law, Public Health issues as required by  law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Law Enforcement: Coroners, Funeral Directors and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Worker’s Compensation: Inmates: Required Users and Disclosures: Under the Law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures
Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physicians’ practice has taken an action in reliance on the use or disclosures indicated in the authorization.

Your Rights
Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.  Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment, or healthcare operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved with your care or for notification purposes as described within this Notice of Privacy Practices.  Your request must state the specific restrictions requested and to whom you want the restrictions to apply.

Your physician is not required to agree to a restriction that you may request.  If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.  You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.  You have the right to obtain a paper copy of this notice from, upon request, even if you have agreed to accept this notice alternatively. i.e. electronically.

You may have the right to have your physician amend your protected health information.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

We reserve the right to change the terms of this notice and will inform you by mail of any changes.  You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our privacy contact person of your complaint.  We will not retaliate against you for filing a complaint.

THIS NOTICE IS PUBLISHED AND BECOMES EFFECTIVE ON/OR BEFORE APRIL 14, 2003.

We are require by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at our Main Phone Number 352-365-6442.

Signature below is only acknowledgeable that you received this Notice of our Privacy Practices.

Print Name:__________________________ Signature______________________Date_______

I authorize the verbal or written release of my information and test results in the event that I am not available to be released to: Name of person(s) to release information to_________________________________________

SIGNATURE_______________________________________________

Since our goal is for you never to be without teeth, we will be inserting your new denture immediately after the extraction of your remaining teeth. This may seem odd, but it is perfectly normal. Typically, after the extraction of teeth, there may be some swelling. By placing your denture in immediately, this swelling can be kept to a minimum. If you did not place your denture immediately, the swelling that occurs might not allow you to wear your denture until the swelling subsides.

It is very important that you follow the post-operative instructions of your dentist or oral surgeon very carefully. You must wear your new Immediate Denture for the first 24 hours (1day) consistently without removing it. This will help to control the swelling. Most likely you have a 24 hour post-operative appointment scheduled for instructions on the placement and removal of your new immediate denture and follow up care as needed.

Since we are unable to try in the denture prior to extracting your teeth, certain esthetic compromises may have to be made. This should not present any significant problem. However, if there are any changes to be made they will be done after your healing period. NOTE: It is normal for the denture to become loose and not feel comfortable. There will be soft-liners placed periodically as needed during your healing process to help with the comfort of your new prosthesis.

Once healing has occurred, after approximately three (3) months, you will either need a reline of your existing denture, or the fabrication of an entirely new denture. If a new one is to be made, we will the be able to make any esthetic changes that you want within the limits of the denture prosthodontics. If a new denture is to be made, you will then be able to use the immediate denture as a spare (emergency) denture. The making of the new denture can take up to 3-4 weeks depending on the stages necessary to complete the denture.

Once healing has occurred and a reline is the treatment needed. You will have to leave the denture for one (1) day. Usually the appointment will be set between 9:00 am and 10:00 am and you will return in the afternoon after 3:30 pm. Is some cases your denture will have to be kept overnight and will be returned back to you the next day after 10:30am. If you have any questions or concerns please do not hesitate to give our office a call so that we may help take care of you needs. (352-365-6442)

With the aid of sedation your surgery will not be unpleasant.  The medications will be given intravenously, and local anesthesia will also be utilized.

A responsible adult MUST bring you to the office, drive you home, and care for you the day of surgery.  We cannot do the procedure if they leave.  Please arrange for someone to be home with you through the day and evening after surgery.  If you are a minor you must bring a parent or legal guardian with you.
DO NOT EAT OR DRINK ANYTHING EIGHT HOURS PRIOR TO YOUR SURGERY.  If medication is taken prior to surgery, swallow it dry or with a very small amount of water.  (ALL your normal medication(s) need to be taken unless instructed otherwise by your doctor or Dr. Vaziri.)
Wear loose fitting, comfortable clothes, short sleeves and comfortable shoes, socks optional
DO NOT wear tight collar or neck tie.   NO contact lens.
Nail polish or panty hose should not be worn.
Please try to empty your bladder prior to surgery.

The profound effects of the sedation will subside prior to your discharge from the office.  However, you should plan to go home and stay in bed or lounge for the remainder of the day or ambulate with help.  If you develop a cold, sore throat, or upset stomach, etc, prior to your surgery, please notify us as soon as possible (352-365-6442).

Please call if you have any questions.

I ____________________________________HEREBY AUTHORIZE DR.______________________ TO RELEASE ANY NEEDED INFORMATION REGARDING MY HEALTH CONDITIONS TO LEADING EDGE DENTAL.

PATIENT:________________________________             DATE:__________________________
                                   Signature

PHYSICIAN’S NAME:_______________________________________________________________

PHYSICIAN’S PHONE:#____________________________ FAX#____________________________

1) REASON FOR MEDICAL CLEARANCE______________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

2) DOES PATIENT NEED PRE-MED?  YES    NO (If yes what is recommended) ______________

3) HOW MANY DAYS SHOULD PATIENT BE OFF COUMADIN/ASPIRIN? ________________

4) WHEN SHOULD PATIENT START BACK ON HIS/HER COUMADIN/ASPIRIN? _________

5) WHAT TYPE(S) OF ANESTHETIC DO YOU RECOMMEND? __________________________

6) WHAT TYPE(S) OF PAIN MEDICATION DO YOU RECOMMEND? ____________________

MEDICAL CLEARANCE REQUESTED BY DR.__________________________________________

MEDICAL CLEARANCE FAXED BY___________________________________________________

_________________________________                  ______________________________
         PHYSICIAN SIGNATURE                                        DATE

Name_________________________________________Address________________________________________
City____________________State___________Zip___________Home#__________________________________
Cell#_______________________ Work#________________________ Birth date_________________ Sex(M/F) Marital Status (S M D W)SS#____________________ Employer______________________________________
Insurance ( Yes / No ) Referred By_________________________________ Email ________________________

Are you under a Physicians care now? _YES Dr's Name & Number____________________________________
Pharmacy________________________________________ Pharmacy Number#____________________________

Do you have a specific dental problem? Yes No	Do you have dental decay or gum disease? Yes No
Do you like your smile? Yes No	Do you have sores or growths in your mouth? Yes No
Do you smoke? Yes No	Do you take oral contraceptives? Yes No

Do you take Bisphosphonates for treatment of Cancer or Osteoporosis? Fosamax,or other medications such as (Aredia, IV Bondronat, Bonefos, Loron, Zometa, IV Reclast, IV Actenel, Didronel, Skelid). Yes No
Do you take aspirin or blood thinners? Yes No (please list type)_________________________________________
LIST ALL YOUR MEDICATIONS:_____________________________________________________________
____________________________________________________________________________________________
ALLERGIES: ( )Penicillin( )Sulfa( )Codiene( )Aspirin( )Latex( )Other:_______________________________
PLEASE check ( X ) if you have any of the following

	AIDS/HIV		Fainting/Dizziness		Osteoporosis
	Anaphylaxis		Glaucoma		Obstructed Sleep Apnea
	Anemia		Heart Attack		Psychiatric Care
	Angina		Heart Murmur		Radiation Treatment
	Arthritis/Gout		Heart Pacemaker		Renal Dialysis
	Artificial Heart Valve		Heart Stent(s)		Rheumatic Fever
	Artificial Joints		Heart Trouble		Shingles
	Asthma		Hepatitis		Sinus Trouble
	Blood Disease		High Blood Pressure		Stroke
	Blood Transfusion		History of Bleeding		Thyroid Problems
	Breathing Problems		Hypoglycemia		Tuberculosis
	Cancer		Irregular Heartbeat		CPAP Usage
	Chemotherapy		Kidney Problems		Bleeding Gums
	Diabetes		Leukemia		Venereal Disease
	Drug/Alcohol Addictions		Liver Disease		Sexually Transmitted Disease
	Emphysema		Low Blood Pressure
	Epilepsy/Seizures		Mitral Valve Prolapse

Please list any other medical conditions that were not listed__________________________________________
____________________________________________________________________________________________
In case of an emergency please notify__________________________________Phone#______________________
***DUPLICATE X-RAYS are available for $10.00 with a 24hr notice.***
Permission is hereby granted to the doctor and/or staff of Leading Edge Dental for such procedures and anesthesia that may be necessary for the care of the undersigned patient.

PATIENT SIGNATURE_____________________________________________DATE_____________________

THERE WILL BE A $25.00 FEE FOR CANCELLED APPOINTMENTS WITHOUT A 24 HOUR NOTICE.

AUTHORIZATION AND CONSENT FOR PHOTOGRAPHY AND PUBLISHING

I_______________________________hereby authorize Dr. Vaziri and Staff to take clinical photographs, videos, or digital images of my condition, both before and after treatment. These images may be presented to scientific, medical, dental and similar groups, including local advertisement publications and/or printed journals and publications for teachings or educations purposes including our internet web site. Although the images will not be labeled with my full name, I am aware that certain images may reveal my identity.

______________________________________________________________________________

All images remain the property of Dr. Vaziri and may be used in the future unless I specifically notify Dr. Vaziri and/or staff in writing that I do not wish the images to be shown.

The undersigned hereby waives any rights to compensation for such uses by reason of the foregoing authorizations, and the undersigned and his successors and assigns harmless from and against any claim for injury or compensation resulting from the activities authorized by the agreement.

I would also be willing to discuss my experiences with other patients or interviewers if contacted.

The term “photograph” as used in the forgoing agreement, shall mean motion picture or
still photography in any format, as well as videotape, videodisc, and/or any other
mechanical means of recording and reproducing images.

Dated:___________________________________________ 20____.

_______________________________________________________

Signature: (Patient/Parent/Conservator/Guardian)

_______________________________________________________

Doctor

_______________________________________________________

Witness