Photo Release

We value our patients' right to privacy and confidentiality, and we take our responsibilities under HIPM and the Texas Medical Records Privacy Act very seriously. Our practice exercises great care in the use of patient images and patient identities.

By signing below, you understand that this authorization may be revoked at any time merely by notifying our office in writing that you wish to no longer allow your photographs to be shared.

Your willingness to allow photography release will have no effect on the treatment or care you receive from our office and staff.


Please sign electronically below.

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Click submit and you hereby give consent to sign this document electronically.

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