GENERAL PHOTOGRAPH/VIDEO RELEASE FORM
I hereby give my consent for SkinPhysicians & Surgeons, Inc., its subsidiaries, licensees, successors and assignees, the right to use, publish and reproduce pictures of me in film or electronic (video) form, and sound and video recordings of my voice , depicting before, during, and after treatment for procedure, performed , for the purpose of being displayed in albums to be shared with prospective patients or via the Internet within medical education settings. I also agree to the use of my photographs and/ or video for general advertising and promotional purposes in any and all media including but not limited to print media, cable and broadcast television, the Internet, social media, brochures and educational seminars. This permission extends to all languages, media, formats, markets and geographies now known or hereafter devised. I understand and agree that these images may be used for an indefinite period of time by SkinPhysicians & Surgeons, Inc., its subsidiaries, licensees, successors and assignees.
I understand that my name will not be revealed therein or by descriptive text or commentary, and when possible, eyes will be obscured to retain privacy. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.
Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.
The undersigned releases SkinPhysicians & Surgeons, Inc., its subsidiaries, licensees, successors and assignees, from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity, or any other claim related to the image or voice recordings. This release includes without limitation any claims related to blurring, distortion, alteration, optical illusion, digital alteration, use in composite form, whether intentional or otherwise, or use of a fictitious name, that may occur or be produced in the processing or publication of the image and/or voice.
By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby.