Consent-form

Client Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number:

Media Consent Form

(ie. Photography, Video, Audio, Social Commentary)

Consent

I, give permission to ……………VisionMD Eye Doctors……………………hereafter referred to as the “Practice” to use my:

Name/Social media tag:

Yes

Testimonial:

Yes

All Media Formats:

Yes

in publications and advertisements or Social Media produced by or for the Practice now or in the future.

My contact details are as follows:

Preferred Display Name:

Position (where applicable):

Instagram:

Tiktok:

Testimonial:

I understand that the items agreed to above may:

1. appear on the Internet/World Wide Web (WWW);
2. appear in print, electronic, or video media;
3. enable readers to identify me.

I understand that if my personal information (name, title, or image) is published
on the Internet/WWW then it will be accessible to users from all over the world. My information can also be searched for using an identifier such as my name, and may be copied and used by any other person using the Internet/WWW. Most importantly, I understand that once my personal information has been published on the Internet/WWW, the Practice has no control over its subsequent use and disclosure.

Signature

Date

Consent-form

Media Consent Form

My contact details are as follows:

Vision MD Eye Doctors

Vision MD Eye Doctors