Permission to Use Photo or Video Image Patient's Name(Required) First Last Today's Date(Required) Month Day Year Clinic Visited(Required)Urgent Care of BerwickUrgent Care of SandflyUrgent Care of Wilmington IslandI hereby grant permission to Your Family Medical Group to use photographs and/or video of me taken on today's date in publications, news releases, online and in other communications related to the mission of Your Family Medical Group. I hereby release the photographer from all claims, demands, and liabilities whatsoever in connection with the photograph and/or video, Additionally, I waive any right to royalties or other compensation arising or related to the use of images taken of me. Consent(Required) I have read and fully understand the terms and conditions.Please select(Required)-choose one-I grant permission to use my photograph or video as stated above.I do NOT grant permission to the use of my photograph or video as stated above.Patient or Guardian of Patient Signature(Required)Today's Date(Required) Month Day Year
