Media Consent Form

Media Consent Form

GOLDEN HILLS PHYSICAL THERAPY
Patient Name

First NameLast Name
Date

MonthDayYear
Date
I hereby give GOLDEN HILLS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY to take and use photographs, video recordings, or written testimonials of me for the purpose of:
- Social Media (e.g., Instagram, Facebook, YouTube)
- Website and digital marketing
- Printed promotional materials
- Educational presentations
Yes, I consent to being recorded/photographed and allow the use of my image, voice, and likeness as described above.No, I do NOT consent to any media usage.
I understand that:
- My identity may be visible depending on the content.
- I can withdraw consent at anytime by providing written notice.
- There is no payment or compensation for the use of this media.
Signature:

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Parent/Guardian Signature (if under 18):

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Clinician/Witness Signature:

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Should be Empty: