Consent And Release for Use of Photographs, Digital Images, Testimonials, and/or Videotapes

Name *

First Name Last Name

For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby authorize Ascent Physical Therapy, PLLC (APT) , aided by such assistants, photographers, or technicians as it may engage for this purpose, permission to use my likeness in a photograph, digital recordings and/or videos in any and all of its publications, including but not limited to all of APT’s printed and digital publications of me before, during, and after any treatment on me. *

I AGREE

I further grant APT the ongoing and unrestricted right to edit, alter, copy, exhibit, publish, distribute, use and reuse the undersigned’s images for general information, education, scientific, medical, and research purposes or for any other lawful purpose which it may deem fit with the understanding that my name will never be used to identify myself. The images may be conveyed or displayed for those purposes, including use in print, on the internet and all other forms of media. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or relating to the use of the photographs, digital recordings and/or videos. *

i AGREE

I agree that APT is the exclusive owner of all copyright and other rights in such photographs, recordings and/or videos and it has the right and unrestricted permission to use, reproduce or publish such photographs, recordings or video in any manner and in any media now known or hereafter discovered or developed *

i AGREE

I further fully consent and agree to allow APT the right to utilize any personal testimonials that I may write, including, but not limited to, any reviews on third-party websites such as Google, Yelp, etc., regarding my treatment at APT’s office. The testimonial may be conveyed or displayed in print, on the internet and all other forms of media. Additionally, I waive any right to royalties or other compensation arising or relating to the use of my testimonial. *

i AGREE

I hereby hold harmless and forever release, waive and discharge APT and it’s office staff, including photographers or technicians, from any and all claims, demands, and causes of actions which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization *

I AGREE

There have been no representations or inducements concerning this consent, except as set forth herein. I am at least 18 years of age and am of sound mind and body. I have read this consent and release and fully understand the contents, meaning, and impact *

I AGREE

AGREEMENT STATEMENT - By clicking this box, I AGREE and certify that based on the above information I fully understand and consent to Photo/Video content produced with those at Ascent Physical Therapy and to the best of my knowledge understand the benefits and risks of doing so to myself and the practice. I represent that I am of sound mind and am legally competent to understand and complete this agreement. I hereby execute this informed consent form without coercion. *

I AGREE

(MINORS ONLY) Checking this box below is a certification that the patient in question is a minor and I am responsible for their care. I hereby agree to informed consent to video/photograph this minor under my care. *

I AGREE Not Applicable

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