Jessica Clark Photography
Please Select all that apply:
Educational purposes (for teaching and/or training)
Marketing or advertising (web, tv, print or social media)
Company website
Restrict use only for my private medical records
I (the Patient) hereby grant and authorize (hereinafter The Company) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all photos and videos taken of me to be used in and/or for any lawful purpose.
This authorization shall continue indefinitely, unless I otherwise revoke this authorization in writing.
I waive the right to inspect or approve any finished product in which my likeness appears.
I agree to this release without being compensated. I waive any right to royalties or other compensation arising or related to the use of the video.
I hereby hold harmless and release The Company from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.
