Photo and Video Release Authorization Form for Concierge Medical Practice

[Practice Name] Concierge Medicine

I, _______________________________ (print name), hereby authorize [Practice Name] and its representatives to take photographs, video recordings, and/or audio recordings of me, including my face, likeness, voice, and person, under the following terms and conditions:

Authorization Scope

• Medical documentation and tracking of conditions/progress
• Educational purposes for medical staff and students
• Marketing materials for the practice
• Social media content
• Website content
• Professional publications

Understanding and Agreement

I understand that:

1. These materials will become the property of [Practice Name]
2. These materials may be used for educational, marketing, or scientific purposes
3. My name and identifying information will be kept confidential unless I provide specific written permission
4. I will not receive compensation for any use of these materials
5. I may revoke this authorization at any time by written notice

Restrictions (if any)

Please specify any restrictions to the use of these materials:

Signatures

Patient Signature: _________________________ Date: _______________

Witness Signature: _________________________ Date: _______________

Practice Representative: ____________________ Date: _______________

Contact Information

Patient Phone: ____________________ Email: __________________________

This authorization is valid for five (5) years from the date of signing unless revoked in writing.