Patient Photo Release and Consent Form
Thank you for sharing photos of yourself with our clinic. We are committed to using these imagesrespectfully and with your full consent. The purpose of sharing these photos is to support andencourage others who are seeking help for their health and well-being through acupuncture andholistic care.
Purpose
The purpose of using these images is to support others who are looking for effective and compassionate careoptions for themselves. By sharing these images, we aim to offer hope, guidance, and relatable stories to individualswho may benefit from acupuncture and natural medicine.
PRIVACY & PROTECTION
- Your face will never be shown in any published or shared materials.- No names or identifying details will be used without additional written consent.- All images will be used respectfully and in ways that preserve dignity and privacy.
CONSENT: Please indicate your permission regarding the use of your submitted photos.
*
YES, I grant permission to Applied Natural Health to use the photos I have voluntarily submitted of myself in the following ways (check all that apply):
NO, I do not grant permission to use my submitted photos.
If you grant permission, please select all the ways your photos may be used:
Clinic website
Social media (e.g., Facebook, Instagram)
Printed materials (e.g., brochures, posters, office displays)
Client education or presentations
Other (please specify)
If you selected 'Other', please specify:
PATIENT AGREEMENT
I confirm that:- I own or have the right to share these images.- I understand that my identity will be protected and face will not appear in any publication.- I understand that no financial compensation will be provided for the use of the images.- I may revoke this consent in writing at any time, though it will not apply to materials already created, distributed, and/orpublished.
Patient’s Full Name
*
First Name
Last Name
Date Submitted
*
-
Month
-
Day
Year
Date
Signature of Patient
*
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Submit Consent
Submit Consent
Should be Empty: