Patient Photo Release Form

Patient Photo Release Form
This form seeks for the consent for photographs to be taken by Hematology and Oncology Associates of Northern California through a doctor or a representative.

By signing this form, the patient affirms in understanding that the the images may be used for different purposes indicated hereunder.

By consenting to the release of images, you agree that you will not receive any form of compensation in cash or in kind.

You likewise understand that your name will not be included in the images. Nonetheless, it is still possible that someone may still recognize you.

Your refusal to consent to the release of your photographs will not, in any way affect the medical care you will receive.

You may rescind your authorization to the release of the photographs by writing us a request.
I authorize the use of Photographs for the following:*

Posting photo in office as inspiration to other patientsHOAONC website and/or social media
Patient Name:*
Signature of Patient:*

Clear
Date Signed:*

MonthDayYear
Date
Upon submitting this form, you affirm that all your responsibilities and rights have been explained to you.
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