Photo / Video Consent & Social Media Release - Pearson Chiropractic & Rehabilitation

Photo / Video Consent & Social Media Release Form

Please fill out the Photo / Video Consent & Social Media Release Form below for Pearson Chiropractic & Rehabilitation Center. Stay Active Live Healthy!

Patient Name *

First

Last

Date *

Clinic Location *

1. Consent to Photography, Video, and Audio Recording

I hereby authorize Pearson Chiropractic & Rehabilitation, its doctors, employees, representatives, and contracted media personnel to photograph, video record, and/or audio record me for purposes including, but not limited to: Patient education, Testimonials, Marketing and promotional materials, Social media content (including but not limited to Instagram, Facebook, YouTube, TikTok), Website use, Internal training and communication, Print or digital advertising.

2. Consent to Use of Images & Recordings

I grant Pearson Chiropractic & Rehabilitation full permission to: Edit, crop, modify, or adapt the material. Use my image, voice, or likeness without restriction. Use the content now or in the future without needing further approval. Share the content publicly or internally as needed. I understand that once published online, content may be publicly viewable and could be reshared by others.

3. No Compensation & No Expiration (Unless Revoked)

I agree that: I will not receive payment or royalties for the use of my image or recordings. This consent does not expire unless I revoke it in writing. Revocation does not require removal of previously published materials.

4. HIPAA Acknowledgment (Patient Privacy)

I understand that: My name or personal health information will not be disclosed without my explicit written permission. Any testimonial I voluntarily provide may include general statements about my care experience.

5. Right to Decline

I understand that refusal to sign this form will not affect my care, benefits, or access to services at Pearson Chiropractic & Rehabilitation.

6. Permission Selection

Please check one:

YES — I give full permission to use my photo, video, and recordings for all marketing, educational, and promotional purposes described above.
YES, WITH LIMITATIONS — I consent with the following restrictions:
NO — I do not give permission to use my photo, video, or recordings.

If you selected YES, WITH LIMITATIONS please provide the restrictions:

7. Signature

Patient Signature: *

Clear Signature

Date *

Parent/Guardian Signature (if under 18):

Clear Signature

Date

Staff Witness:

Clear Signature

Date