Chiropractic Practice Photo and Video Release Form

[Practice Name] [Address] [City, State ZIP] [Phone]

Patient Information

Name: _________________________ Date: _____________ Date of Birth: __________________

Authorization

I, ______________________, hereby authorize [Practice Name] and its representatives to take and use photographs, video recordings, and/or digital images of me for the following purposes:

• Documentation of clinical conditions and treatment progress
• Educational materials and professional training
• Marketing materials including website, social media, and printed materials
• Scientific publications and presentations

Terms and Conditions

1. I understand that these images may be used for:

   • Clinical documentation in my medical record
   • Teaching purposes within the healthcare community
   • Marketing and promotional materials
   • Scientific literature and presentations

2. I understand that:

   • I may revoke this authorization at any time in writing
   • Revocation will not affect any actions taken before the revocation
   • I will not receive compensation for the use of these images
   • These images will be stored securely according to HIPAA guidelines

Release

I hereby release [Practice Name] from any liability connected with the taking, recording, digitizing, or publication of photographs, video, or digital images.

Duration

This authorization shall remain in effect until revoked in writing.

Signatures

Patient Signature: _________________________ Date: _____________

Witness Signature: _________________________ Date: _____________

If patient is a minor: Parent/Guardian: __________________________ Date: _____________