Patient Release for Medical Photographs
Vein Specialists of the Carolinas request permission to use your photographs to help promote healthy vein care. The photographs taken will be used for testimonials on our website, brochures, and/or television commercials. We will keep your identity confidential.
Please read the following and initial accordingly:
______I agree to allow Vein Specialists of the Carolinas to take photographs of my legs for insurance purposes. (Some insurance companies require photographs to be taken for approval of any procedures.)
______ I grant Vein Specialists of the Carolinas permission to use my photographs on their website, brochures, and/or television commercials. I waive any rights to royalties or other compensation related to the use of these photographs.
______ I agree to release and hold harmless Vein Specialists of the Carolinas, from and against any claims, damages, or liability arising from or related to the use of the photographs.
By signing this form I confirm that this release form has been explained to me in terms which I understand.
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Signature Date
