Please Fill Out the Form Below

Media Release Form

"*" indicates required fields

Please be advised that throughout your time in our office, you may be photographed, videotaped or interviewed. With your consent, any photo, video, or interview may be reproduced and released for use in the media such as newspapers, brochures, the internet and/or any social media platforms.

Please indicate your preference below.

Consent Yes
Consent No
MM slash DD slash YYYY

If Patient is a Minor

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.