Media Consent

For release of images/videos/information for multi-media and/or marketing purposes.

I give my permission for Travis Shaw MD | Skincare by Shaw to use my image(s) and/or video(s) including description(s) of the services performed for publication/broadcast. Media outlets utilized include, but are not limited to; print, electronic, social, and other types of multi-media advertisements. My images/videos may be included in both internal and external marketing/public relations. This images and information may be used indefinitely for any length of time in the future, unless otherwise requested.
Please select media outlets that you are comfortable sharing your results:

All forms of media Website In-office slideshows and books Trade shows, meetings, & special events Electronic or print newsletter Postcards or print mailings Facebook, Instagram and other social media
Patient Signature

Clear
Date

Month Day Year
Date
Patient Print Name
Witness Signature

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Witness Print Name
Patient Contact Information:
Address:
Email & Telephone #:
example@example.com
8730 stony point parkway suite 120 | richmond va | 23235 | 804.775.4559
Should be Empty: