Social Media Photo/Video Release Form

Social Media Photo Form: Authorization, Release, and Consent

Greater Cleveland Pediatrics, 31100 Pinetree Road, Suite 215, Pepper Pike, OH 44124
If you are open to sharing fun photos of your children on our website or social media accounts, please fill out this form. If that doesn’t sound like something you're interested in, no worries, you are not required to complete this form! See more details below.
Patient Name*

First NameLast NameSuffix
Age of Patient*
Patient Date of Birth*

MonthDayYear
Date
Gender
Primary Phone*

Area CodePhone Number
Parent Email (if UNDER 18 years old)
example@example.com
Patient Email (if OVER 18 years old)
example@example.com
Can we use your child's name?*

Complete nameFirst nameNicknameAnonymous
Please select all applicable:

I authorize and grant Greater Cleveland Pediatrics to take my child's photo or video. I understand that I will be asked prior to any photos or videos being taken whenever my child is in the office for a medical visit.I grant Greater Cleveland Pediatrics to use my child's photos on Facebook, Twitter, Instagram, and other social media platforms.I allow Greater Cleveland Pediatrics to edit, alter, copy, or distribute the photos for social media advertising and marketing.
By signing this form, I agree to the following: (Please select all)*

I agree that the photos belong to Greater Cleveland Pediatrics.I understand that I will not receive any monetary compensation.I understand that photos will not disclose any identifying medical information or condition; they will be positive, fun photos only!
Parent Signature (if patient is UNDER 18 years old) - OR - Patient Signature (if patient is OVER 18 years old)*

Clear
Name of Parent or Guardian Consenting: *

PrefixFirst NameLast NameSuffix
Date Signed*

MonthDayYear
Date
Should be Empty:

Social Media Photo Form: Authorization, Release, and Consent