Patient Photo Release Form

Patient Photo Release Form
This form seeks for consent for photographs and videos to be taken by the Blossoms of Hope Kentucky Inc. owner or a representative.

By signing this form, the client affirms an understanding that the images or videos may be used for different purposes indicated hereunder.

By consenting to the release of images and videos, you agree that you will not receive any form of compensation in cash or in kind.

You likewise understand that your name will not be included in the images. Nonetheless, it is still possible that someone may still recognize you.

Your refusal to consent to the release of your photographs or videos will not, in any way affect the services you will receive;
I authorize the use of Photographs/Videos for the following:

Educational Purposes such as Service DemonstrationSocial Media and Online Publishing adsPrint Marketing AdvertisementsVideo and Television Media Advertisements
Name of Patient
Signature of Parent/Participant

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: