Your Name:_____________________________________________
Brief description of your video clip:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I want the clip edited (must be done if the clip is longer is
than
2 minutes):_________________________
I vouch that I personally performed the surgery recorded in the
clip. Please sign:
_________________________________
I want to be listed as the author: ____
I want to remain anonymous: ____
My e-mail address is: ________________
My telephone number: _______________
My address: ____________________________________
If sending a video tape, please have video cued to the beginning of the clip & include appox. running time
Signature:_________________________________