Authorization And Consent To Photograph Or Film

AUTHORIZATION AND CONSENT TO PHOTOGRAPH OR FILM
The undersigned hereby authorizes Wilcox Fertility (WF) to photograph/film or permit other persons to photograph/film the patient/person named below. The undersigned agrees that WF may use and permit other persons to use the negatives or prints prepared from such photographs/film for the purposes and manner, as either may deem appropriate.

The undersigned also agrees the photographs/film/video may be used for purposes including, but not limited to dissemination to WF staff, physicians, health professionals and members of the public for educational, treatment, research, scientific and charitable purposes. Such dissemination may be accomplished in any manner and that such use is subject only to the following limitations:
Please list any limitations (if any)
The undersigned has entered into this agreement in order to assist scientific treatment, education, or public relations and hereby waives any right to compensation for these uses by reason of the foregoing authorizations.

The undersigned and his or her successors or assigns hereby hold that WF, its employees and physician(s), and any other person participating in my care and their successors and assigns harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.

The term “photograph” and “film” as used in this agreement shall mean motion picture or still photography in any format, as well as videotape, and any other mechanical means of recording and reproducing images.
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(Employee/patient/parent/conservator/guardian)
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