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Model Release Form

Get permission to snap photos before you take out your camera. Protect your client’s likeness and copyright with a free model release form. Customize this model release form to list your terms and conditions. Capture legally binding digital signatures with our smooth signature widget.

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Please fill out the following information to grant permission for the use of your likeness.

Email*

Full Name*

Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Date of Birth*

Select date

10.

Gender*

Male

Female

Other

Description:Protect your client’s likeness and copyright with a free model release form. Customize this form to list your terms and conditions and capture legally binding digital signatures with our smooth signature widget.

A model release form is a legal document that grants permission to the photographer or videographer to use the model's likeness in their work. This form protects the client's rights to their image and ensures that the photographer has the necessary permissions to use the images. Our customizable model release form allows you to list your terms and conditions, ensuring that both parties are on the same page. Our smooth signature widget makes it easy to capture legally binding digital signatures, streamlining the process for both you and your client. With our model release form, you can snap photos with confidence, knowing that you have the necessary permissions to use them.

First Name*

Last Name*

Address*

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Student Name*

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First Name*

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Full Name*

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Consent to Telemedicine Services*

I understand that telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of evaluation, diagnosis, consultation, treatment, and/or follow-up. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

Consent to Treatment*

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential. I understand that there are both benefits and risks associated with telemedicine, including but not limited to, the possibility, despite reasonable efforts on the part of my healthcare provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

Consent to Payment*

I understand that I am responsible for payment of all fees associated with telemedicine services and that my insurance may not cover these services. I understand that I will be billed for telemedicine services in the same manner as for in-person services.

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