The Practice desires to utilize the Images for purposes of professional publications, training, education, or clinical evaluation as well as on Social Media, including posting on social media accounts, including but not limited to the Practice’s website, Facebook, Instagram, Snapchat, Pinterest, RealSelf, LinkedIn, Google+, Twitter, etc. (collectively, “Social Media”), and including such use in Practice’s email marketing campaigns both of which will result in the publication and distribution of protected health information to the general public. The Practice IS NOT receiving direct or indirect remuneration from a third party in connection with the use/disclosure of the protected health information described in this authorization. 

THIS AGREEMENT PROVIDES PRACTICE WITH MY CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING PRACTICE TO PUBLICIZE, COMMERCIALLY EXPLOIT, AND OTHERWISE USE MY LIKENESS AND NAME AS SET OUT ABOVE. BY CHECKING THE BOX, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT, THAT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE PRACTICE AND THAT THIS CONSENT IS IRREVOCABLE.