Photo/ Video Consent & Release Form

Please Initial:
initial I consent that the photographs/videos taken of me, or parts of my body can be used for the purpose of my medical/cosmetic care with River Region Dermatology & Laser | River Region Aesthetics.
initial   The photographs and all details regarding medical/cosmetic services rendered to me will be kept confidential within my personal medical history file at River Region Dermatology & Laser | River Region Aesthetics
initial   In addition to the photo consent above, I hereby give my consent for River Region Dermatology & Laser | River Region Aesthetics to use the photographs/videos under the following circumstances:

• I consent to internet use, as defined: Photographs/videos taken of me or parts of my body as well as details regarding medical/cosmetic services that I have received at River Region Dermatology & Laser | River Region Aesthetics can be used on the company's website/social media to inform the public about medical/cosmetic methods. I give my consent as a voluntary contribution in the interest of public education, and my consent is subject only to the condition that I am not identified by name or any other identifying marks at any time during any use or publication of these materials by any party.
• I consent to media use as defined: Photographs/videos taken of me or parts of my body as well as details regarding medical/cosmetic services that I have received at River Region Dermatology & Laser | River Region Aesthetics can be used in any print or broadcast media, including, but not necessarily limited to newspapers, pamphlets, educational films, internet, and television, in order to inform the public about medical/cosmetic methods. I give my consent as a voluntary contribution in the interest of public education, and my consent is subject only to the condition that I am not identified by name at any time during any use or publication of these materials by any party.

By signing this form, I acknowledge my consent as initialed, and I further recognize that this consent form will supersede any other photo consent forms with a prior date. This consent may be revoked at any time by written request or by completion of a new form.