PHOTOGRAPH/VIDEO & INFORMATION RELEASE AUTHORIZATION

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East Lake Acupuncture, LLC
NOTE:This form is NOT required for photos or videos of patients used for the purposes of treatment or diagnosis, where the photo and/or video becomes part of the patient’s medical record and is not used for any other purpose.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Which services are you interested in receiving during your photo shoot?

AcupunctureCuppingMassage (15 min.)B12 shotsHomeopathic Pain injectionsEar seedsMigun TableKT TapingWhatever is available, I'm not pickyOther
PHOTOGRAPH/VIDEO AUTHORIZATION
Information Release - Check to confirm you have read and understand

I understand that the image(s) I’ve authorized for disclosure may be seen by members of the general public. If I’ve authorized release of image(s) for medical or educational purposes, I understand that the images may be seen by scientists, medical researchers, and medical students and teachers, as well as by members of the general public.
Use of name - Check only ONE

I consent to the use of my name, occupation, and/or city/state of residence (John Smith, Accountant, St. Cloud, Florida). I understand that I may be identified by name in printed, internet or broadcast information that might accompany the photo or video image of me.I consent to the use of my first name and last initial only, or first initial and last name only. (Example: J. Doe, Nurse, St. Cloud, Florida, or John S., Personal Trainer, Orlando, FL). I understand that it's possible I might be identified by name in printed, internet or broadcast information that might accompany the photo or video image of me.I do not consent to the use of my name. I understand that, even though my name will not be used, it is possible that someone may recognize me based on the image(s) alone.Other
I authorize the use of the following information about me, my medical condition, or my treatment (check only one)

Type of service received (acupuncture, massage, cupping, etc.)Condition being treated (migraines, low back pain, etc.)Both the type of treatment(s) and the condition being treatedOther
REVOCATION & EXPIRATION OF RELEASE AUTHORIZATION

You may revoke this Authorization at any time: the revocation will not apply to information that has already been released in response to this Authorization.

You must revoke this Authorization in writing.

The procedure for revoking this Authorization is to mail your written revocation to:

East Lake Acupuncture, 1551 Budinger Ave., Saint Cloud, FL 34769 or fax it to (321) 340-3522.

You may refuse to sign this Authorization: East Lake Acupuncture, LLC, will not condition your treatment, any payment, enrollment in a health plan, or eligibility for benefits on receiving your signature on this Authorization.

Unless you specify an expiration date, under "Special requests/comments/conditions, this Authorization shall remain in effect indefinitely.

You will not receive any type of compensation for the use of your image(s).
I authorize East Lake Acupuncture to take, or have taken, photographs or videos, or allow third-parties to take photographs or videos of me for the following purposes:

For marketing/promotional purposes (advertising, social media posts, website(s), blog posts, etc.)In professional journals and other publications,In the public media, such as newspapers,In presentations, publications, brochures,
Check each box to indicate you read and understand it.

I understand that: I may revoke this Authorization at any time: the revocation will not apply to information that has already been released in response to this Authorization. I must revoke this Authorization in writing.I am aware that I shall not receive any type of compensation in exchange for the use of my image(s).
I certify that I am at least eighteen (18) years of age at the signing of this document

I am 18 or olderI am a parent or legal guardian, signing for a minor child
I have read and understand the information in this Authorization form.
Printed Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

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PHOTOGRAPH/VIDEO AUTHORIZATION