AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT PHOTOGRAPHIC AND/OR VIDEO IMAGES
The photographic/video images, and/or
testimonial will be used for: Social Media
I understand that I may revoke this
authorization at any time, but such revocation
must be in writing and received by the practice
via registered mail. Revocation affects
disclosure moving forward and is not
retroactive. This authorization expires 99 years
from the date signed.
NO TREATMENT CONDITIONS:
I understand that the practice cannot condition
treatment on whether or not I sign this
IF PERSONAL REPRESENTATIVE:
IF PATIENT IS A MINOR:
This form is provided by The Well of Life Center for Natural Health, LLC for general convenience purposes and does not represent legal advice. Additional compliance rules vary from state to state, country to country. If you feel like you need legal consultation in addition to what we’ve provided, be sure to consult your practice attorney including seeking advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services regulations. We are NOT attorneys, and although this form is based on our own research to ensure compliance, it does not represent legal advice.
In Case of Emergency, please contact:
Health & History Questionnaire
Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity/allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).