Photo Release Form

First Name *

Last Name *

Phone *

Email *

Date of birth *

Gender

Address *

City *

State *

Postal code *

Authorization and Release

Please check the boxes regarding your preference. *

I authorize Towamencin Family Chiropractic to take my photographs.

I authorize Towamencin Family Chiropractic to use my photos on Facebook, Twitter, Instagram, and other social media platforms.

I authorize Towamencin Family Chiropractic to edit, alter, copy, or distribute the photos for social media advertising and marketing

I agree that all intellectual property rights of the photos belong to Towamencin Family Chiropractic

I agree that I will not receive any monetary compensation for the usage of my photographs in social media platform

What is your preference regarding the use of your name? *

I consent to the use of my complete name.

I consent to the use of my first name only.

I consent to the use of my nickname

I consent to the use of my photographs anonymously

Signature *

Date Signed *