Free Patient Photo Release Form Template

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Free Patient Photo Release Form Template

Patient Photo Release Form

Please fill out the following release form with the correct information.

Patient Information

Name

    Date of Birth

      Address

        Phone number

          Email

            Authorization Details

            I, the undersigned, hereby authorize[Your Organization Name]to use photographs and/or videos of me for the purposes indicated below. I understand that these images may be used in various formats, including print, digital media, or educational materials, and may be shared publicly.

            Intended Use

              • Educational Purposes

              • Marketing and Advertising

              • Social Media

              • Research and Publications

              • Internal Use Only

              Terms of Agreement

              1. I understand that my image may be used without compensation.

              2. I acknowledge that my participation is voluntary and can be revoked by written request at any time.

              3. I confirm that this release form has been fully explained to me, and I understand its contents.

              Date:

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