I grant permission to Eye Plastic Surgery, Ltd. and/or W Cosmetic Surgery, PC and its employees and agents to use photographs and/or video taken of me for use in educational and promotional materials including the practice website www.wcosmeticsurgery.com, all forms of social media (Facebook, Instagram, X and LinkedIn), in office education and scientific publications. I give permission for full face photographs to be shared.
I understand that any photographs used for the above purposes will not include any identifying information about me, including my name, date of birth, address, etc.
I hereby waive any right to inspect or approve the finished photographs/video, or the printed or electronic materials that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photographs/video.
I hereby agree to release, defend, and hold harmless, Eye Plastic Surgery, Ltd. and W Cosmetic Surgery, PC and its employees and agents, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on web sites or social media, from and against any claims, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution.
I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. I also am free to revoke this consent at any time by submitting my revocation to the above address in writing. I understand that my revocation of this release will apply to future uses of my photographs/video and does not include any use, publication or distribution that has already occurred.