Social Media Photo and/or Video Release Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Guardian Name if Minor
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Authorization, Release, and Consent
Can we use your name?
Complete name
First name
Nickname
Anonymous
I authorize and grant Eyes of East Sac to take my photos or video regarding my experiences with them.
I grant Eyes of East Sac to use my photos or a video of me on Facebook, Twitter, Instagram, and other social media platform.
I allow Eyes of East Sac to edit, alter, copy, or distribute the photos or video for social media advertising and marketing.
I agree that the photos and/or video belong to Eyes of East Sac
I understand that I will not receive any monetary compensation.
Signature or Guardian Signature if Patient is a minor
Name of Parent if Patient is a Minor
First Name
Last Name
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: