This is an authorization to permit Joseph B. DeLozier III, M.D. to use my photographs for patient education purposes
I authorize the use of these images for the following specific purposes:

I understand that:
1) I will not be identified by name in any of the media described above; however, I also understand that in some circumstances that photographs may display features that identify me (such as necklaces, tattoos, skin markings etc.)
2) 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 this office at 209 23rd Ave North Nashville, TN 37203

This authorization is made as a voluntary contribution in the interest of public education. My signature certifies that I have read this authorization and consent carefully and fully understand its terms