Photography Release Form

Patient Photography Release Form
Patient Name*

First NameMiddle NameLast Name
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
This authorization allows McLean Dermatology and Skincare Center, Potomac Dermatology and Skincare Center, Dr. Lily Talakoub, Dr. Amanda Lezanski-Gujda, Sarah Walker, FNP, Nadia Herrera PA-C, Jennifer Spyridakis, FNP, and staff representatives to take photographs and/or video of my body for medical purposes to be used for my care as a patient, marketing literature, and/or case presentations. I understand the following: *
Patient Name*

First NameLast Name
Parent/Guardian Name if Patient is Under the Age of 18

First NameLast Name
Signature of Patient OR Guardian/Parent*

Clear
Date*

MonthDayYear
Date
Should be Empty: