Authorization and Release to be Photographed

Lakeside Dermatology

Please correct the errors described below.

I authorize Lakeside Dermatology to take my photograph (iPad /digital camera/video may be used). These photos may then be used by Lakeside Dermatology for promotional purposes including but not limited to, advertising, publicity, commercial or display of use. I also authorize my photos to be posted on all social media including but not limited to Facebook, Twitter, their webpage, etc. By signing this, I verify that I have received a copy of this authorization form for my records.

DISCLAIMER: By signing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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