Social Media Photo Release Form
Name
First Name
Last Name
Age
Date of Birth
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Gender
Male
Female
Non-Binary
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorization, Release, and Consent
Can we use your name?
Complete name
First name
Nickname
Anonymous
Type a question
I authorize and grant Moonlight Medical Spa to take my photos regarding my experiences with them.
I grant Moonlight Medical Spa to use my photos on Facebook, Twitter, Instagram, and other social media platform.
I allow Moonlight Medical Spato edit, alter, copy, or distribute the photos for social media advertising and marketing.
I agree that the photos belong to Moonlight Medical Spa.
I understand that I will not receive any monetary compensation.
Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: