Nutrition Practice Photo and Video Release Form

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

MEDIA CONSENT AND RELEASE

I, ______________________________ (print name), hereby grant permission to [Practice Name] and its representatives to photograph and/or video record me and to use such media for:

• Before/after documentation of nutrition progress
• Educational materials and presentations
• Marketing materials (print and digital)
• Social media content
• Website content
• Professional publications

TERMS OF AGREEMENT

1. I understand that these photographs/videos may be used for the purposes listed above without any compensation to me.

2. I understand that my identity may be disclosed through descriptive text or commentary.

3. I understand that all media will be owned by [Practice Name].

4. I release [Practice Name] and its representatives from any claims that may arise from these images/videos, including claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, or copyright.

REVOCATION

I understand that I may revoke this authorization at any time by providing written notice to [Practice Name]. Revocation will not affect any actions taken before the receipt of this written notification.

SIGNATURES

Patient Signature: _________________________ Date: __________

Printed Name: ____________________________

If patient is under 18:

Parent/Guardian Signature: _________________ Date: __________

Printed Name: ____________________________

Witness Signature: ________________________ Date: __________

Printed Name: ____________________________