Time
Room #
In
Out
Proc. Start
Proc. End
Recovery Time
Pre-Op Checklist
Allergies
Consent
H & P
Photos
Derma Tech
Portolio
Video
 
Information Diagnostic/Loc.
Patient Name*Date*
Sensitivity TestLocation*
Date*Reaction
Type of Proced.
Scar Description
SizeDescription
Age of Scar
Colors
Pigments
Brands
Needle Sizes
Anesthetic
Micro-Gel
Other
Medication
Other
Prep
Position
Post-Op Medication
Other

 

Photo Release

For good and valuable consideration, the receipt of which is hereby acknowledged, I, [text* full-name], hereby grant Michele Kinser permission to use my likeness in a photograph in any and all its publications, including but not limited to all of Michele Kinser's printed and digital publications. I understand and agree that any photograph using my likeness will become property of Michele Kinser and will not be returned.

I acknowledge that since my participation with Michele Kinser is voluntary, I will receive no financial compensation.

I hereby irrevocably authorize Michele Kinser to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing Michele Kinser's programs or for any other related, lawful purpose. In addition, I waive the right to inspect or approve the finished product including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

I hereby hold harmless and release and forever discharge Michele Kinser from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

 

Printed Name:*Date:*
Signature:*
Signature
Signature of guardian if under 18 years of age