Sample Photograph Release Form

RELEASE AND AUTHORIZATION FOR USE OF PHOTOGRAPHS

FOR VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, I hereby grant (Name of Clinical Facility) the irrevocable right and permission, throughout the world, in connection with the photograph(s) that were taken of me or which I provided to (Name of Clinical Facility), (copies of which photographs are annexed hereto and made a part), the following: the right to use and reuse, in any manner at all, said photographs, in whole or in part, modified or altered, either by themselves or in conjunction with other photographs, in any medium or form of distribution, and for any purposes whatsoever, including, without limitation, all promotional and advertising uses, and other trade purposes, as well as using my name in connection therewith, if (Name of Clinical Facility) so desires.