Before-and-After Patient Photo Release Form
Patient Name:
Date of Birth:
Procedure(s) Performed:
I authorize the use of my before-and-after photographs for the following purposes:
Website
Social Media
Print Materials
Educational/Training
I understand that my identity will remain confidential and only my images will be used.
I consent to my identity being revealed in association with my photographs.
Additional Comments or Restrictions:
Patient Signature:
Date:
Witness Signature:
Date: