Patient Photo Release Authorization

I authorize Dr. Roth, MD and/or SkinLab West Ave, and/or their representative(s), to take photographs, slides/videos of me or parts of my body for the following procedure(s) and for medical purposes to be used for my care, medical presentations and/or articles. I hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery, Inc.

In addition, I authorize the use of these images, without compensation to me, for the following specific purposes:

I understand that:
Such photographs, slides/videos may be published by Dr. Roth, MD and/or SkinLab West Ave in any print, visual or electronic media including, but not limited to, medical journals and textbooks, scientific presentations, teaching courses, and internet web sites, for the purpose of informing the medical profession or the general public about plastic surgery methods. I understand that such uses may also include marketing on behalf of Dr. Roth, MD and/or SkinLab West Ave, for which Dr. Roth, MD may receive direct or indirect remuneration. I will not be identified by name in any of the media described above; However, I also understand that in some circumstances the photographs, slides/videos may display features that identify me.

I have the right to revoke this authorization in writing at any time and, if I decide to do so, I must present my written revocation to Dr. Forrest S. Roth at 2800 Kirby Drive, Ste. B212. A revocation shall not affect any release of information made prior to revocation in reliance upon this authorization. If I fail to specify an expiration date, event, or condition, this authorization will expire with my written revocation.

I may refuse to sign this authorization without such refusal affecting the medical treatment I receive from Dr. Roth, MD and/or SkinLab West Ave.

The information disclosed under the authorization, or some portion thereof, is protected by state law and/or The Federal Health Insurance Portability and Accountability Act of 1996 (HIPPA). Any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal and/or state confidentiality rules.

A copy of this Authorization is valid as the original. I have received a copy of this authorization. I may inspect or copy information to be used or disclosed under this authorization, as provided by federal and/or state law. I release and discharge Dr. Roth, MD and/or SkinLab West Ave from all liability, including liability for negligence, that in any way arises out of any and all rights that I may have had in photographs, slides/videos of me that I have authorized to be used and disclosed in the authorization; and any claim that I may have or may have had relating to such use and disclosure of those photographs, slides/videos of me, including any claim for payment in connection with any distribution or publication of them in any medium.

This authorization is made as a voluntary contribution in the interest of public education and certify that I have read this Authorization and Release carefully and fully understand its terms. If I have questions about the use of disclosure of my photographs, slides/videos, I can contact the practice at 713-559-9300.

Your appointments are very important to all members of our team as West Ave Plastic Surgery. Time allocation for an appointment is reserved especially for you. We do understand that sometimes schedule adjustments are necessary; therefore, we respectfully request at least 24 hours' notice for adjustments to your appointments and for cancellations. All are policies are designed to benefit our guests and to provide the best quality and tradition of excellent service for our established and future clientele.

Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and clients on our waiting list miss the opportunity to receive services they need. We ask that all new and current guests supply a credit card to have on our files. If we do not receive the required notice for adjustments and cancellations, the following fees will be applied to your card or alternatively billed out to you:

No-Shows or Last-Minute Cancellations will result in a $150 fee. *Notification given at least 24 hours prior to your appointment will not be charged*

We do not offer refunds on services rendered. Aesthetic results are quite variable from person to person. and while we do our best to achieve the desired outcome, it cannot always be guaranteed. Clients are responsible for further treatments need to achieve further results. If you have pre-purchased and have not received the service, your payment will be applied to your account as a credit for future use but will not be refunded.

We do not offer refunds on products purchased. Defective products can be exchanged for the same product only and must be done within 30 days of purchase. Gift Cards are non-refundable.

If you put down a deposit with any of our providers and you cancel last minute, or miss your appointment, you forfeit your deposit. To book a new appointment, you must pay a new deposit.

Should you need to cancel an appointment for any reason, you must provide our office with 24 hours' notice; otherwise we will be forced to collect a $150 cancellation fee on your next visit. This policy also applies when you are 15+ minutes late to your appointment. If at any point you cancel two or more appointments within 30 days of each other, you may be discharged from the program. This is the only way to ensure that your results are maximized within the allotted time of your course of therapy.

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED POLICIES. I AM STATISFIED WITH THE EXPLANATION AND AGREE TO FULLY COMPLY.