Photo Release Form

Photo Release Form
Authorization For Use Or Disclosure Of Patient Photographic and/or Video Images
Name

First NameLast Name
Authorization:

I authorize the use and disclosure of my photographic/video images, and/or testimonial for marketing purposes by Pua Manu MedSpa. I understand that information disclosed pursuant to this authorization my be subject to redisclosure and may no longer be protected by HIPPA privacy regulations.
Purpose:

The photographic/video images, and/or testimonial will be used for: Social Media and/or advertising
Revocability:

I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the Pua Manu MedSpa via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.
No Treatment Conditions:

I understand that the practice cannot condition treatment on whether or not I sign this authorization.
"Yes, I would like a copy of this form

NOYES
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Authorization For Use Or Disclosure Of Patient Photographic and/or Video Images