Photo and Media Release Form

 

Patient Name  

I,  hereby grant permission to Independence Women's Clinic, its agents and assigns, to use the above-named patient's photo, video and/or likeness for promotional purposes. This includes, but is not limited to, use in news releases, photographs, videos, audio recordings, websites, marketing, advertising, social media and other promotional and exhibition materials, for an indefinite period of time.

I grant unrestricted permission for these images, videos and recordings of the patient/child to be used in print, digital and internet media. I understand that these materials may be used for a variety of purposes, and I agree that they may be used without further notification to me.

I acknowledge that I will not receive any compensation for the use of these materials, and that Independence Women's Clinic retains all rights to the images, videos, recordings and any derivative works created from them.

I waive any right to inspect or approve the final use of any printed or electronic copy. I hereby release Independence Women's Clinic and its agents and assigns from any claims arising from the use of these materials, including but not limited to claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright.

Yes, I consent to the use of photos, videos and recordings for promotional purposes as described above.

No, I do not consent to the use of photos, videos and recordings for promotional purposes as described above.

Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.