Associates in Women's Healthcare
Delivering Women's Health

Forms

Patient Forms

Medical Records Release


Photo Release

Name *
Name
Release
I, (the “Releasor”) grant permission and consent to Associates in Women's Health (the “Releasee”) for the use of the following photograph(s) as identified below for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content: Description: Pictures of minor child I understand that there shall be no payment for this release. I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. I, the Releasee, understand and agree to the aforementioned terms and conditions.