Photo & Video Release Form

Photo/Video Release Form

(Aesthetics)

Date:

Patient Information

Patient Name:
Date of Birth:

Photo/Video Release Authorization

I hereby grant permission to Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C., and related entities to take photographs and/or videos of me for the following purposes:

Medical documentation and record keeping
Educational purposes
Marketing and promotional materials
Website and social media use
Before and after treatment documentation

Consent Statement

I understand that these images may be used for the purposes indicated above and I release all rights to these images. I understand that my identity may or may not be disclosed in connection with these images.

I consent to the use of my photos/videos as described above

Signature

Patient Signature: (Sign below)

Date:

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.

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Your legal name

Your email address

Please Confirm full name and signature.

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Type In Signature

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

February 1, 2026 11:11 pm EDT

Photo & Video Release Form Uploaded by ENNU Patient Docs - admin@ennulife.com IP 24.238.5.27