Consent/ Release For Photographs/ Videotapes

Consent/ Release For Photographs/ Videotapes
Section A:

This section must be completed prior to taking photographs or videotapes
I hearby (initial desired response):

___ grant permisson

___ do not grant permission

to Advanced Family Foot and Ankle Agents to take photographs and/ or videotapes of:
Section B:

This Section Must be completed if permission was obtained in Section A.
I understand the purpose of the photographs/ videotapes and authorize the use of such photographs or video images/ sound (initial desired items):

___ for documentation in the medical record

___ for the professional or public publication/republication

___ for public information media

___ as deemed necessary by my physican

___ other:

I understanf that my identity (initial desired response)

___ may be released

___ may not be released

I agree to hold Advanced Family Foot and Ankle and its agent harmless from any and all liability arising from these activities.
Section C:

The section must be completed if Section A and/ or B is completed.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Section A: