PHOTO SUBMISSION FORM

To submit a photograph of a patient, the attestation statement below must be completed. This attestation is not necessary for submissions of isolated diagnostic studies, such as EKG's, radiographs, gram stains, etc. Appropriate masking of patients is also required.

CC: (1 line)

HPI: (approximately 5 lines)

PE: (describe only pertinent positives and negatives. It is not necessary to describe findings seen in the photo.)

LAB: (pertinent)

IMAGING: (describe only if pertinent and not shown in photo.)

QUESTION: (short-answer. No more than two questions)

ANSWER(S):

DISCUSSION: (1-2 short paragraphs. Keep to < 150 words)

TAKE HOME POINTS: (limit 3)

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I,_________________________________, am submitting this patient's photograph (s) for consideration of publication on Emguiz.com. I attest that I have obtained written consent and release of responsibility from the patient in the photograph or the legal guardian of this individual.

Signature:____________________________ Date:__________________