Pmu Media Release Form
This form seeks to get your consent to use your photos/videos are taken by our company through our therapist or representative. Signing this form gives us the permission to use your photos/videos for the purposes indicated hereunder. The refusal of this form by you will not affect the operation or medical care you receive in any way.
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Please select the ones you agree;
I grant my full permission to take my photos/videos by your company “before” and “after” of the operation.
I give my permission to use, re-use, publish my taken photos/videos in portfolios, advertising, publicity, trade, sale. I won’t demand any charge, royalty or any monetary compensation.
I give your company the right to use my name regarding these purposes.
Date
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Month
-
Day
Year
Date
Sign
Submit
Should be Empty: