Consent for Photo and Video Use

Patient Information
Patient Name*
First Middle Last
Patient Date of Birth*
MM slash DD slash YYYY
Legal Guardian*
Email*
Consent for Video and Pictures
Consent for Photo and Video Use
I give permission for my child to be photographed and/or videotaped for the purposes of education, training and public relations. The identity of the children will be treated confidentially and your child's full name will not be revealed.
Consent
- I agree to the use of photos and videos of my child by Cheshire Center Speech and Voice.
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Email
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Patient Information