Kings Medical Eye Care P.C. KCE Form

Media Release Form
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I full name grant permission to Kings Medical Eye Care PC, hereinafter known as the Kerato NYC and its affiliates to use my image (photographs and/or video) for use in Media publications including, but not limited to Instagram, Facebook, Twitter, YouTube Channel, TikTok, KERATO NYC and its affiliates website, magazines (for advertisement purposes) etc. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or video recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area and unrestricted time.
I hereby waive any right to inspect or approve the finished photographs or electronic matter 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 image. Initials
I am 21 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. Initials
I full name DO NOT give Kings Medical Eye Care PC permission to use my images/video in any Media publications.
Patient's Signature 3*

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Patient's Signature
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Name*

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Should be Empty:

	Yes	No	Please explain (if Yes)
Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat problems (e.g. hearing loss, sinus, sore throat)
Heart problems (e.g. chest pain, irregular heartbeat)
Respiratory problems (e.g. shortness of breath, wheezing, cough)
Gastrointestinal problems (e.g. heartburn, belly pain, diarrhea, nausea)
Urinary problems (e.g. pain, frequent urination, blood in urine)
Skin problems (e.g. rashes, dermatitis, excessive dryness and itching)
Musculoskeletal problems (e.g. muscle aches, joint pain or swelling)
Neurological problems (e.g. numbness, weakness, headaches)
Psychiatric problems (e.g. depression, anxiety)
Endocrine problems (e.g. diabetes, thyroid)
Blood Disorders (e.g. leukemia)

Kings Medical Eye Care P.C.

Dr. Alexander Movshovich, MD, PHD

Kings Medical Eye Care P.C.

Patient Medical History Record

Media Release Form