Audience Feedback Facial Consent Form
Please provide your feedback and consent regarding the use of your facial appearance/capture. This form is for non-medical, non-HIPAA purposes only.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Organization or Event Name (if applicable)
Are you comfortable with your facial appearance being recorded or captured for feedback purposes?
*
Yes, I am comfortable
No, I am not comfortable
Please indicate how your facial appearance may be used (select all that apply)
*
Internal feedback or training
Marketing or promotional materials
Public presentations or events
Other
How comfortable are you with your facial data being used for the purposes selected above?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Do you have any specific concerns or preferences regarding the use of your facial appearance/capture?
Would you like to receive updates or results related to this feedback and consent process?
Yes, please keep me informed
No, I do not wish to receive updates
Signature (please sign below to confirm your consent)
*
Submit Consent
Submit Consent
Should be Empty: