Photo/Video Release Form
Photo/Video Release
We are active on social media and enjoy sharing our patient's progress (with your permission). If not, no problem! Like our facebook pages and follow us on instagram.
Name
*
First Name
Last Name
Select one:
*
Yes, I give my permission for my (or my child's) photograph and/or video to be used for advertising/informational purposes on the company's website and social media.
No, I do not give my permission for my (or my child's) photograph and/or video to be used.
Electronic Signature
*
Date of signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: