• Consent/ Release For Photographs/ Videotapes

  • Section A:

    This section must be completed prior to taking photographs or videotapes
  • 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):


  • I understand the my identity may be:

  • Clear
  •  -  -
    Pick a Date
  • Should be Empty: