PHOTOGRAPH/VIDEO & INFORMATION RELEASE AUTHORIZATION

NOTE:This form is NOT required for photos or videos of patients used for the purposes of treatment or diagnosis, where the photo and/or video becomes part of the patient’s medical record and is not used for any other purpose.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Which services are you interested in receiving during your photo shoot?

Information Release - Check to confirm you have read and understand

Use of name - Check only ONE

Other

I authorize the use of the following information about me, my medical condition, or my treatment (check only one)

REVOCATION & EXPIRATION OF RELEASE AUTHORIZATION

You may revoke this Authorization at any time: the revocation will not apply to information that has already been released in response to this Authorization.

You must revoke this Authorization in writing.

The procedure for revoking this Authorization is to mail your written revocation to:

East Lake Acupuncture, PO Box 700215, Saint Cloud, FL 34770 or fax it to (321) 340-3522.

You may refuse to sign this Authorization: East Lake Acupuncture, LLC, will not condition your treatment, any payment, enrollment in a health plan, or eligibility for benefits on receiving your signature on this Authorization.

Unless you specify an expiration date, under "Special requests/comments/conditions, this Authorization shall remain in effect indefinitely.

You will not receive any type of compensation for the use of your image(s).

I authorize East Lake Acupuncture to take, or have taken, photographs or videos, or allow third-parties to take photographs or videos of me for the following purposes:

Check each box to indicate you read and understand it.

I certify that I am at least eighteen (18) years of age at the signing of this document

I have read and understand the information in this Authorization form.

Printed Name

Signature

Date

PROMOTIONAL SERVICES SIGN-UP

PHOTOGRAPH/VIDEO AUTHORIZATION