media-consent | Palermo Orthodontics

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Media Release Consent Form

Consent *

PALERMO ORTHODONTICS MEDIA RELEASE CONSENT

I hereby consent to be interviewed, recorded, photographed, videotaped or filmed by representatives of Palermo Orthodontics for purposes of publication on ,

display or broadcast media
print, web, social media and digital display
and all other forms of media within the organization’s related properties and websites.

I agree that such interviews, recordings, articles, quotes, photographs, films, audio or video and/ or any reproductions of same in any form, are the property of the Palermo Orthodontics, and I relinquish any present or future claim for reimbursement for said photographic or film reproduction of my likeness or for said testimonials by me.

I hereby release Palermo Orthodontics, its affiliates, employees, representatives and agents from any and all claims, demands, costs and liability that may arise from the use of these interviews, recordings, photographs, videotapes or films, and/or any reproductions of same in any form, as described above, arising out of being interviewed, recorded, photographed, videotaped or filmed.

I acknowledge that I have read this consent form in its entirety, or it has been read (or translated) to me, and I have had the opportunity to ask questions about it and understand it.

First Name *

Last Name *

Email Address *

Phone Number

Date Signed *

Signature *

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Signing on behalf of *

I am a parent signing on behalf of a minorI am signing on behalf of myself (I am the patient)Please indicate if you are the parent signing on behalf of a minor or signing on behalf of yourself.

Patient First Name *

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