Patient Consent Release Form "*" indicates required fields I hereby grant permission for the use of any record, illustration, photograph or other imaging record created in my case, for use in examination, testing, credentialing and / or professional certifying purposes.Print Name*Email* Primary Care Doctor (PCP):Pharmacy name:Pharmacy address:Date* MM slash DD slash YYYY Patient Signature*In addition, I grant permission for the use of photographs to be used in any advertisement, including the use of photographs on the professional website of the above stated physician as well as Facebook, Instagram and Active Campaign upon request.Print Name*Patient Signature*Date* MM slash DD slash YYYY By submitting this form I agree to the Terms of UsePhoneThis field is for validation purposes and should be left unchanged. Δ
