Photo/Video Release

This form authorizes the use of photo, video, audio and any other multimedia.

Authorization to use photo and/or audio-video materials

I, the undersigned, hereby authorize Artificial Limb Specialists and any of it's sponsors or partners to use, reproduce, and/or publish photographs and/or video that may pertain to me — including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on the company's or project sponsor's Internet Web Page. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, the company or project sponsor may publish materials, use my name, photograph, and/or make reference to me in any manner that the company or project sponsor deems appropriate in order to promote/publicize service opportunities. I understand I may terminate this authorization by providing written notice to Artificial Limb Specialists at any of their offices.
Name of patient * First Last
Name of person to appear in photos/videos/etc.
Date * / MM / DD YYYY
Name of parent or guardian if signing for a minor First Last
Relationship to patient
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Patient ID (admin to enter)
Type the letters you see in the image below.