Consent/ Release For Photographs/ Videotapes

Consent/ Release For Photographs/ Videotapes
Name

First Name Last Name
Section A:

This section must be completed prior to taking photographs or videotapes
I hereby:

Grant Permission Do not Grant permission
To Advanced Family Foot and Ankle Agents to take photographs or videos.
Section B:

This Section Must be completed if permission was obtained in Section A.
Section C:

The section must be completed if Section A and/ or B is completed.
I understand the purpose of the photographs/ videos and authorize the use of such photos or video imaged/ sound (Select desiered items):
For documentation of medical records for professional or public publications/ republication For public media (Youtube, social media, and website) as deemed necessary by my physician
I understand the my identity may be:
May be released may not be released
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Section A: