Patient Consent Release

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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.

First Name*

Last Name*

Email Address*

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Primary Care Doctor (PCP)*

Pharmacy Name*

Pharmacy Address*

Date*

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.

First Name*

Last Name*

Signature

Date*

By submitting this form, you expressly consent to receive calls, text messages, and emails from Lozada Facial Plastic Surgery regarding appointments, treatment updates, billing, and other service-related communications. These messages are not for marketing purposes. Message frequency may vary. Msg & data rates may apply. Reply HELP for assistance or STOP to opt out of text messages at any time.

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Patient Consent Release

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