Social Media Consent Form

Social Media Consent Form
I give permission to Professional VisionCare and The Solution Center to use my name, testimonial, and/or photograph in publications produced by or for their office(s) for present or future use.

I understand that these items may appear on the internet, appear in print, electronic, or video media, and/or enable readers to identify me. I understand that if my personal information is published on the internet, it will be accessible to the public.

I understand that once my personal information has been published on the internet, Professional VisionCare and The Solution Center have no control over its subsequent use and disclosure.
Patient Name*

First NameLast Name
Date

MonthDayYear
Date
If patient is a minor, please type in guardian's name:
Signature of Patient (or Guardian)

Clear
Should be Empty: