Patient Photograph and Video Release Form

I understand that photographs and/or videos may be taken of me or parts of my body before, during, and

after surgery. These images may be shared with staff, other physicians or health professionals, and

members of the public for educational and marketing purposes. I hereby give my consent for Dr.

_________________ to use the photographs under the following circumstances:

Please initial JUST ONE of the following:

_____I OPT OUT. I do not want my photographs to be used for advertising or marketing. They will only

including but not necessarily limited to newspapers, pamphlets, educational films, practice website, and

television, in order to inform and educate the public or other physicians about plastic surgery.

_____ALL MEDIA INCLUDING SOCIAL MEDIA: Photographs and/or videos taken of me or parts of my

body as well as details regarding medical services that I have received may be used on social media

sites, including but not necessarily limited to Facebook, Instagram, Snapchat, Twitter, RealSelf, and other

outlets, in order to inform the public or other physicians about plastic surgery. I understand that once my

images are published, I lose control and rights to these images. I understand that once my images are

published, the individual social media platforms may assume control and rights to those images. I also

understand that images posted on the Internet can be altered and/or archived, and are permanent and

searchable.

PLEASE REVIEW AND INITIAL EACH OF THE FOLLOWING:

_____REVOCATION: I understand that I may revoke this authorization at any time; however, such

revocation must be in writing and received via registered mail. Revocation affects disclosure moving

forward and is not retroactive.

_____EXPIRATION: This authorization expires 99 years from the date signed

_____VOLUNTARY CONSENT: I understand that my participation is voluntary. If I do not sign this form,

my healthcare and payment for my healthcare will not be affected.

_____I will not receive compensation for my participation.

_____By signing this form, the personal health care information I relay or allow to be relayed to an

outside source, such as social media platform or news source, is no longer protected by state and federal

Patient Name ________________________________________________________________________

Patient or Guardian Signature____________________________________________________________