MediaRelease | Holistic Health Associates

Media Release Form
Patient Name*
First Last
Consent
By signing below, I consent and authorize Holistic Health Associates to copyright, use and publish any of the images or media in any format taken of me. I understand these images may be used for a variety of purposes and may appear on Holistic Health Associates website, newsletter, promotional materials or any other media now known or to be invented. I also understand that Holistic Health Associates or any entity authorized by Holistic Health Associates, will use the images and/or media exclusively for purposes relating to Holistic Health Associates and not for any commercial gain. These images will never be sold or released to a third party.

By signing below, I acknowledge and understand the vulnerability and accessibility of images and information on the internet and printed materials; including but not limited to downloading images from the internet or make copies from printed materials. I agree that Holistic Health Associates is not responsible for unauthorized use of the images or media. I am aware that I am not entitled to any compensation or other consideration for the use of these images.

By signing below, I acknowledge I have read and understand this release. I affirm that I am at least 18 years of age, or, if I am under 18 years of age, I have obtained the required consent of my parents/guardians as evidenced by their signature below.
Signature of Patient, Legal Representative, or Parent/Guardian*
Your Name
Your Name
Your Name
By completing this box, you have digitally signed the Holistic Health Associates Media Release Form.
Date*
Month
Day
Year
Printed Name of Patient, Legal Representative, or Parent/Guardian
Relationship to Patient
- Patient
- Parent/Guardian

Media Release Form