Consent to use photographs

Name(Required)

I consent to photography taken before, during, and after my surgery/procedure/treatment. I understand that these photos will remain in my medical chart and are used as part of my medical care. The photos and its details regarding medical services rendered to me will be kept confidential within my personal medical history file at Northwestern Specialists in Plastic Surgery (NSPS). The photographs taken will become property of NSPS. The photographs may be published in Scientific Journals and/or shown for scientific/ educational reasons, and may be used for educational purposes on the NSPS website and social media. In addition, photos (and chart material) may be used by the American Board of Plastic Surgery or credentialing purposes.

I agree to allowing my photographs to be displayed on any of the following:(Required)
I request that my photographs be:(Required)
MM slash DD slash YYYY

Contact Us Today!

Northwestern Specialists
Plastic Surgery

676 N St Clair Street, Suite 1575
Chicago, IL 60611

Monday-Friday 8a-5p
Saturday: 9a-2p
Sunday: Closed

Northwestern Med Spa Streeterville

676 N St Clair Street, Suite 1575
Chicago, IL 60611

Monday: 8a-6p
Tuesday-Thursday: 8a-7p
Friday: 9a-5p
Saturday: 9a-2p
Sunday: Closed

Northwestern Med Spa River North

3 E Huron Street, 3rd Floor
Chicago, IL 60611

Monday-Thursday: 10a-7p
Friday 9a-5p
Saturday: 9a-2p
Sunday: Closed

© 2022 NSPS. All Rights Reserved. Site Developed by Softgrid.