Media Consent Form
  • Media Consent Form

  • Format: (000) 000-0000.
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    Permission to use pictures. I hereby grant to Professional the full right to take, publish, and reproduce photographs/videographs of me, my face, eyes, and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch the photographs/videographs as deemed necessary by Professional. I further expressly assign any copyright in these photographs/videographs to the Professional. I also grant my consent for Professional to use my image and likeness as contained in these photographs for any advertising or other purposes, along with comments I may provide.

  • If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorney's fees. Any claims arising out of this Agreement will be resolved though binding arbitration using the rules of the American Arbitration Association.

    I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this Agreement, or if I am under 18 years of age. I have had my parent or legal guardian consent to this Agreement, and his or her relationship to me is as follows. By his or her signature below, he or she ratifies and consents to this procedure under these terms. 

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