Patient Consent Release Form

I hereby grant permission for the use of any record, illustration, photograph or other imaging record created in my case, for use in examination, testing, credentialing and / or professional certifying purposes.
Print Name*
Email*
Primary Care Doctor (PCP):
Pharmacy name:
Pharmacy address:
Date*
Date Format: MM slash DD slash YYYY
Patient Signature*
In addition, I grant permission for the use of photographs to be used in any advertisement, including the use of photographs on the professional website of the above stated physician as well as Facebook, Instagram and Active Campaign upon request.
Print Name*
Patient Signature*
Date*
Date Format: MM slash DD slash YYYY
By submitting this form I agree to the Terms of Use
Phone
This field is for validation purposes and should be left unchanged.