Authorization:
I authorize the use and disclosure of my name,
photographic/ video images, and/or testimonial for
marketing purposes by the practice listed below.
I understand that information disclosed pursuant
to this authorization maybe subject to redisclosure
and may no longer be protected by HIPAA privacy
regulations.

Purpose:
The photographic/video images, and/or testimonial
will be used for: Social Media and/or Advertising.

Revocability:
I understand that I may revoke this authorization at
Any time, but such revocation must be in writing and
Received by the practice via registered mail.
Revocation affects disclosure moving forward and is
not retroactive. This authorization expires 99 years
from date signed.

No Treatment Conditions:
I understand that the practice cannot condition
Treatment on whether or not I sign this authorization.