Optional permission to use your photos or videos in our marketing.
This form is optional. Saying no will not affect your care in any way.
Clinical photos taken for your treatment are part of your health record and are covered by our Notice of Privacy Practices; this form does not change that. This form is only about using photos or videos of you in Style 3 Demo's marketing.
You can withdraw this permission at any time by telling Style 3 Demo in writing. We will stop new uses, but we may not be able to recall materials already published or printed. You will not be paid for any use.
Once a photo or video is published, anyone can see, copy and share it, and it is no longer protected by federal privacy law.
You are entitled to a copy of this form.
By signing below, you confirm the information you gave is accurate to the best of your knowledge and you agree to sign this form electronically. Your electronic signature has the same effect as a handwritten one. You can ask Style 3 Demo for a paper copy of this form at any time.
Please sign in the box above.
Your information is encrypted and transmitted securely under HIPAA.
