MEDIA CONSENT FORM

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Patient Name
First Name
Last Name
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Date of Birth
Date
Month
Day
Year
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Email
example@example.com
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I AUTHORIZE DR. NIRMAL S. JAYASEELAN , STAFF MEMBERS, PAID CONTRACTORS, OR BUSINESSES HIRED BY THE INDIVIDUAL OR ORGANIZATIONCheck all the apply:
SOCIAL MEDIA: Photographs and/or videos taken of me as well as details regarding medical services that I have received may be used on social mediasites, including but not necessarily limited to Facebook, Instagram, TikTok and otheroutlets, in order to inform the public or other physicians about bariatric surgery. I understand that once myimages are published, I lose control and rights to these images. I understand that once my images arepublished, the individual social media platforms may assume control and rights to those images. I alsounderstand that images posted on the Internet can be altered and/or archived, and are permanent andsearchable.
PRACTICE WEBSITE ONLY: Photographs taken of me as well as detailsregarding medical services that I have received may be used on the Dallas Bariatric Center website without disclosure ofpersonal information in order to inform the public about bariatric surgery methods. I understand that oncethese images are placed on a digital platform, they can be altered and archived, and are permanent, andsearchable.
ADVERTISING: Photographs taken of me as well as details regarding medical services that I have received may be used in any print or broadcast media, including but not necessarily limited to newspapers, pamphlets, educational films, practice website, and television, in order to inform and educate the public or other physicians about bariatric surgery.
I OPT OUT. I do not want my photographs to be used for advertising or marketing. They will onlybe used for my medical chart.
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PLEASE REVIEW EACH OF THE FOLLOWING:
I release Dallas Bariatric Center from any claims, liabilities, and obligations in regard to obtaining or using the materials.
VOLUNTARY CONSENT: I understand that my participation is voluntary. If I do not sign this form,my healthcare and payment for my healthcare will not be affected.
REVOCATION: I understand that I may revoke this authorization at any time; however, suchrevocation must be in writing and received via registered mail. Revocation affects disclosure movingforward and is not retroactive.
I/We, the undersigned, hereby agreed that we have read this agreement and accept it.
I OPT OUT. I do not want my photographs to be used for advertising or marketing. They will onlybe used for my medical chart.
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Patient Signature
Clear
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Date Signed
Date
Month
Day
Year
Should be Empty: