Figure 1 Patient Consent Form United Kingdom final.doc Google Docs 1.pdf

AUTHORISATION FORM
I understand that Figure 1, Inc. (the "Recipient") makes available an image-sharing application called the Figure 1 Application (the "App") that is used by healthcare professionals and others to share de-identified images of medical conditions or injuries. My physician or other healthcare professional has asked me, and I hereby agree, to allow him or her to:

  1. take photos (or otherwise capture images, such as by a scan or X-ray) of part of my body (the "Images");
  2. remove any identifying details that would allow someone to identify me from the Images; and
  3. transfer the Images to the Recipient to be shared with other users of the App for educational and informational purposes to promote the sharing of medical knowledge.

I understand that I may revoke this Authorization at any time prior to the images being transferred to Figure 1. My revocation will only be effective if I submit it in writing to User. I understand that I am not required to sign this Authorization, and that my refusal to sign will not affect my eligibility for treatment, services or other benefits provided to me by User. I understand that, in accordance with the App’s terms of use, the Images are only to be transferred by the User to the Recipient after the Images have been fully de-identified and that the Recipient will have no means to connect my identity to the Images. Accordingly, the de-identified Images will no longer constitute personal data and will not be protected as such. I understand that the de-identified Images may be used for additional purposes by the Recipient in connection with products and services that may be developed in the future. I understand that I will receive no compensation for consenting to the capture or use of the Images.

Signature of Patient or Patient’s Representative
Print Name

Date
Description of Representative’s Authority to Act for Patient