Photography Release Form

Address

This authorization allows McLean Dermatology and Skincare Center, Dr. Lily Talakoub, Dr. Isabela Jones, Sarah Walker, FNP and staff representatives to take photographs and/or video of my body for medical purposes to be used for my care as a patient, marketing literature, and/or case presentations. I understand the following:
Name of Individual Completing this Form

First Name Last Name
Relationship to Patient
Contact Number of Individual Completing this Form

Area Code Phone Number
Signature

Clear
Should be Empty:

Patient Photography Release Form