Photo, video & testimonial authorization

Optional authorization for the specific materials and uses below. This is separate from treatment consent. This blank form does not collect or send information online. Practice review is needed before using it with patients.

Consent information

Individual nameSpecific photographs, recordings, words or other information authorized (file IDs / dates / description)Persons authorized to use or disclose: LK Fitness & Therapy, LLC, and the named staff or vendors belowRecipients and approved channels (specific website, social accounts, print, advertisements or audiences)Purpose of each approved useMay name / voice / face / health details be used? State exactly what is permitted and any editing limitsExpiration date or event (required)Third-party payment to the practice for this marketing, if any; specify or write “none”

I authorize only the uses described above. Signing is voluntary. Treatment, payment, enrollment or eligibility for benefits will not depend on signing. I may revoke this authorization in writing by delivering a signed request to LK Fitness & Therapy, LLC; call 267-647-9097 for the secure delivery method. Revocation cannot undo actions already taken in reliance on this authorization. Public recipients may redistribute the material, and it may no longer be protected by HIPAA. I will receive a copy of the signed authorization.

Individual or authorized representative signature / dateRepresentative name and authority to act, if applicablePractice verification / copy provided date

Store signed forms separately from a reusable marketing-image folder. Link an internal permission-record reference to the exact asset; do not store patient names or signed forms in an advertising collection.