Patient Photo Release Form

Patient Photo Release Form
This form seeks consent for the use of photographs and/or video by Multicare Specialists. By signing this form, the patient affirms in understanding that the the images may be used for different purposes indicated hereunder. By consenting to the release of images, you agree that you will not receive any form of compensation in cash or in kind. Your refusal to consent to the release of your photographs will not, in any way affect the medical care you will receive; You may rescind your authorization to the release of the photographs by writing us a request;
I authorize the use of Photographs for the following:*

Educational Purposes such as Medical Procedure DemonstrationSocial Media and Online Publishing adsPrint Marketing AdvertisementsVideo and Television Media Advertisements
Name of Patient*
This authorization shall remain in place until*

MonthDayYear
Date
Signature of Patient*

Clear
Date Signed*

MonthDayYear
Date
Upon submitting this form, you affirm that all your responsibilities and rights have been explained to you.
Should be Empty: