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Photography Release Form

Date: ___________________

Patient #: ______________________

Name (please print): ______________________________________________________________
I hereby give permission for my photograph to be taken by Dr. King or Lakes Cosmetic Institute staff
to be used to evaluate my skin thoroughly, keep sequential records and to allow the doctor and staff
to communicate with me more completely.
Signature: ______________________________________________________________________
Furthermore, if checked below, I give permission for my photos and /or testimonial to be used for
the following purposes:
___ Newspaper

___ Videos

___ Magazines

___ Commercials/TV

___ LCI Website

___ Internet/intranet

___ Posters/Rack Cards

___ Social Media (Facebook Twitter, YouTube)

The materials will not contain my name or any other personal identifying information, but may contain
images that would give away my identity.
I have the opportunity, at my request, to review any materials that