PHOTO CONSENT AND RELEASE FORM Patient Name: I consent

PHOTO CONSENT AND RELEASE FORM

Patient Name: _________________________

I consent for photographs and/or video images to be taken of me by AesthetiSpa, Inc. or a

representative. I understand the images will be a part of my medical record and may be used for

purposes of medical teaching or training or for marketing purposes (website, print, digital or

social media).

By consenting to photographs and/or video images I understand I will not be compensated from

any party. Although photographs and/or video images will be used without identifying

information such as name, I understand it is possible someone may recognize me.

I further acknowledge that my participation is voluntary and agree that use of any photographs

and/or video images confers no rights of ownership or royalties whatsoever.

I authorize the use of photographs and/or video images: (please initial indicating YES or NO

below)

________ YES ________ NO For educational purposes (medical teaching

or training),

________ YES ________ NO For marketing and advertising purposes

(website, print, digital, or social media),

________ YES ________ NO At my request, my photographs and/or video

images will only be used as part of my medical record.

I hereby release AesthetiSpa, Inc., its employees, and any third parties involved in the creation of

or publication of educational or marketing materials, from liability for any claims by me or any

third party in connection with my participation.

By signing this form, I confirm understanding of this consent. If I wish to withdraw my consent

in the future, I may do so via written request submitted to AesthetiSpa, Inc. or by completion of a

new form.

Patient Signature: ______________________ Date: ________________