PHOTOGRAPHY CONSENT FORM

Please correct the errors described below.

Pediatric Health & Wellness recognizes the need to ensure the welfare and safety of all individuals taking part associated with our practice. We will not permit photographs, video or other images of children to be taken without the consent of the parents/guardians. The images will be placed in the patient’s chart, and will only be used for treatment of your child. Pediatric Health & Wellness will take all steps to ensure these images are used solely for the purposes they are intended.

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

Your message will be encrypted.