Authorization to Publish Photographs

Full name:
Nationality:
Profession:
RG:
CPF:
Address:
Legal guardian (if applicable):
Kinship degree:
Name of Physician:

Object: Photographs of the GRANTOR (S) dated from: ..............(describe photographs including diagnosis).

Through this document I authorize, free of charge, for unlimited time and in any territory, SOCIEDADE BRASILEIRA DE DERMATOLOGIA (BRAZILIAN SOCIETY OF DERMATOLOGY), registered with CNPJ/MF under number 42174094/0001-65, to reproduce my image, as detailed in the object of this authorization, for publication in its scientific quarterly Surgical & Cosmetic Dermatology, as well as on its website (http://www.surgicalcosmetic.org.br), with no restrictions regarding its circulation and for use in all scientific and educational purposes not expressly mentioned here.

I declare that I am aware that my features may be visible and, therefore, recognizable, in the pictures to be published and used for all purposes mentioned in the previous paragraph. Notwithstanding, I authorize their use with the proviso that my name is not to be used with any of the images used by the SOCIEDADE BRASILEIRA DE DERMATOLOGIA.

Finally, I surrender any rights of use and publication of my pictures linked to the present authorization, exempting the SOCIEDADE BRASILEIRA DE DERMATOLOGIA and its professional members of any lawsuit regarding these rights.

.................., ...........de..............de.............(place and date)

Signature:_________________________________________________________ Name:

Witnesses:

1)_____________________________________________________________________
Nome:
CPF:

2)_____________________________________________________________________
Nome:
CPF:

* If the patient is a minor or unable to give written permission for any reason, the authorization should be granted by the patient’s legal guardian.