Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorization, Release, and Consent
Can we use your photos?
Yes, but keep it anonymous
For office and educational purposes only
Yes, but don't use my face
Yes you can use my face if necessary
I authorize and grant Elite Skin Center to take my photos.
I grant Elite Skin Center to share my photos on Facebook, Instagram, and other social media platforms for advertising and marketing.
I agree that the photos belong to Elite Skin Center.
I understand that I will not receive any monetary compensation.
Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Submit
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