DO YOU OR ANY OF YOUR BLOOD RELATIVES (I.E. GRANDPARENTS, PARENTS, BROTHER, OR SISTER) HAVE ANY OF THESE CONDITIONS?
PROCEED TO CONSULTATIVE Rx FORM
DR. MEDINA'S OPTICAL
I, ________ (the "Patient" or "Patient's legal representative") understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Dr. Ariel Medina will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies.