Photography Release Form

Patient Photography Release Form
Patient Information
Patient Name

First Name Middle Name Last Name
Date of Birth

Month Day Year
Patient Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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