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.

Your information will be encrypted.