Patient demo

I authorize Michael R. Whetstone, M.D., and associates or assistants of their choice, to take photographs of the treatment site for
record purposes on


I agree and authorize use of the photos for teaching purposes, which include being shown to other patients. I am aware that my name and identity will not be disclosed.

I DO NOT authorize the use of these photos for teaching purposes.


I agree and authorize use of the photos in selected advertisements of the above-mentioned physician. I am aware that my name and identity will not be disclosed.

I DO NOT authorize the use of these photos for advertising.


I agree and authorize the above-mentioned physician to place my photos on his professional web site. I am aware that my name and identity will not be disclosed

I DO NOT authorize the use of these photos on any web site.

I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature