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1. I am over 18, or have parental consent for this computer imaging.
2. The photos submitted are of myself, not of another party and the e-mail address is also mine. I am not
making a request for imaging on behalf of any other person.
3. Computer Imaging is intended for informational use only and should not be construed as medical advice, medical treatment or the conveyance of medical services in any manner whatsoever.
4. I understand that the pictures and alteration of these pictures seen are solely for the purpose of illustration of possible results that may be achieved by cosmetic surgery and are not a guarantee of actual surgical results that might be achieved.
5. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics, health and healing characteristics. I further understand that cosmetic surgery may not be necessary or appropriate for me.
6. I further understand and acknowledge that because of the obvious significant differences in how living tissue reacts to surgery; there may be no relationship between the electronic images created, and my actual final surgical result.
7. I hereby agree that the photos that are imaged will become the property of Dr. Vitolo and will be held in confidence. If I wish the return of my original photos, I will request that in writing.
8. I certify my understanding that there is NO WARRANTY, expressed or implied, as to my own final appearance after elective surgery by the use of these electronically altered images. I hereby release Dr. Vitolo from any and all claims with respect to information I receive based upon imaging requested by me.
9. The photos transmitted by me will be kept in confidence at our Computer Imaging Center and become the property of Dr. Vitolo.
10. Dr. Vitolo reserves the right to refuse to image a photo for any reason whatsoever. This promotion for free imaging services may be withdrawn at any time for any reason.
11. I agree that I will not represent to any third party or other medical provider that images created by the Computer Imaging Center constitute a guarantee or promise of a particular surgical result.
12. I understand that this is not a "secure site" and that E-mail may be viewed by other persons during transmission and that Dr. Vitolo is not responsible for any consequences that may arise from such unauthorized interception of E-mail.
