Consent For Use Of Photography, Video And Other Images

I, (name) grant to this facility the right and permission to use images of me for the following purposes:

(check all that apply)

•	Use in my chart only
•	To be shown to other clients and potential clients to demonstrate possible results
•	Newspaper or online advertising
•	All purposes, including marketing purposes in all media

By signing this form, I give this facility and related companies or organizations the right and permission to use my name and images or photographs of me for the purposes above as well as educational purposes and release this facility from harm or detrimental consequences that may be experienced as a result of usage of these images in these ways. I release my images from confidentiality requirements as agreed.

I make these statements voluntarily and agree that all information contained herein is accurate. I understand that my image may be used in marketing and other activities without limit unless my selections above restrict usage.