Patient Photo and Video Release Authorization Form

I, _______________________ (print name), hereby authorize _______________________ (urgent care facility name) and its representatives to take, reproduce, use, publish, and distribute photographs, digital images, and/or video footage of me for the following purposes:

Authorized Uses

• Medical documentation and clinical records
• Educational materials and training
• Marketing and promotional materials
• Website and social media content
• Other healthcare-related publications

Terms and Conditions

1. I understand that these images/videos may be used in various formats, including but not limited to:

   • Print materials
   • Digital platforms
   • Social media channels
   • Educational presentations

2. I acknowledge that:

   • I will not receive compensation for the use of these images/videos
   • All images/videos will remain property of the urgent care facility
   • I may revoke this authorization in writing at any time

Privacy Considerations

• This authorization is valid until revoked in writing
• Medical privacy laws (HIPAA) will be respected in the use of these materials
• Patient confidentiality will be maintained as required by law

Signatures

Patient Signature: _________________ Date: _________________

Witness Signature: _________________ Date: _________________

If patient is a minor: Parent/Guardian Signature: _________________ Date: _________________

Facility Information

Facility Name: _________________ Address: _________________ Phone: _________________

A copy of this authorization will be provided to the patient upon request.