PRX Plus Before & After Photo Consent Form
Please provide your details and review the consent options carefully.
Full Name
*
First Name
Last Name
ID / Passport Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Clinic Name
*
Treating Practitioner Name
*
Consent for Use of Images
*
I CONSENT to use of my images for marketing/promotional purposes
I DO NOT consent to marketing/promotional use
I understand that PRX Plus before and after images may be used for educational, marketing, social media, website, training, or promotional purposes. My identity may be partially or fully anonymised unless otherwise agreed.
Social Media-Specific Consent
Yes
No
I also consent to my images being used on social media platforms (Instagram, Facebook, TikTok, etc.) for PRX Plus educational and promotional content.
Revocation Clause
I understand that I may withdraw my consent for future use of my images at any time by contacting the clinic in writing. I understand this will not affect images already published or distributed.
Data Protection & Confidentiality Clause
My information and images will be handled in accordance with applicable data protection laws and will be stored securely by the clinic and/or PRX Plus distribution partners.
Patient Signature
*
Date (Patient)
*
-
Month
-
Day
Year
Date
Treating Practitioner Signature
*
Date (Practitioner)
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: