THIS FORM MUST BE SIGNED BEFORE ANY PHOTOGRAPHY IS UNDERTAKEN
Name of Photographer
I permit the photographer named above and his/her licensees or assignees to use the photograph(s)and/or video from and any other reproductions or adaptations there from either complete or in part alone or in conjunction with any wording and for all uses including digital and print media publicity and/or merchandising and/or editorial purposes in any country. Unless otherwise agreed the photograph(s) and any videos or adaptations thereof shall be deemed to represent an imaginary person. No changes to the terms of this release are accepted unless agreed in writing by the photographer, his/her assignees or licensees or myself.
I understand that I do not have any interest in the copyright to the photograph(s) nor shall I receive any payment.
I am over 18 years old.
Name of clinic
Name of client
Address of client
Signature of client Date