Consent for Photography

Consent for Photography & Media Release

I, the undersigned, or the legal representative of the patient ("Patient"), hereby consent to photographs, videos, digital or audio recordings, and/or images ("Photography") being taken by Dripping Wellness, LLC, its healthcare providers, and staff (collectively, "Provider"

I understand that:

The Photography will be used to document my care and may be part of my medical record, protected under HIPAA and Dripping Wellness, LLC's Notice of Privacy Practices.Dripping Wellness, LLC will own the rights to the Photography, and I will not receive any compensation for its use. However, I may request to view or obtain copies of anyPhotography that becomes part of my medical record

Additionally, I authorize Dripping Wellness, LLC to use the Photography for: Marketing & Social Media (website, brochures, social media posts, educational content, promotions Before & After Comparisons for patient education and promotional materials. Advertising & Educational Purposes to showcase the results of services and promote wellness education.

I understand that my identity may be protected if requested, and no sensitive or compromising images will be shared without prior approval. I also understand that I have the right to withdraw consent at any time by submitting a written request to Dripping Wellness, LLC.

acknowledge that I have read this consent in its entirety, had my questions answered, and voluntarily agree to the terms above.

Patient Name

Patient Signature

Date

Dripping Wellness, LLC 7520 NW 5th Street Suite 200, Plantation, FL 33317