Photography Consent Form/Release CommentsThis field is for validation purposes and should be left unchanged.Please Read and Agree to the Following:(Required)I hereby grant permission to Medrock Pharmacy, LLC to use photographs and/or digital images of me and/or statements or testimonials from me for use in promotional and/or educational materials. These materials might include printed or electronic publications, websites (including Facebook and other social media accounts) or other electronic communications. I agree that my first name and city of residence may be revealed in descriptive text or commentary in connection with the image(s), statements or testimonials. I acknowledge and agree that MedRock Pharmacy, LLC will provide compensation for compound costs incurred by me, subject to the terms and conditions. Notwithstanding the foregoing, I authorize the use of these images, statements and/or testimonials without additional compensation to me and understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. All digital reproductions and prints shall be the property of MedRock Pharmacy, LLC. I understand that I may revoke this authorization at any time by notifying Medrock Pharmacy, LLC in writing. The revocation will not affect any actions taken by Medrock Pharmacy, LLC before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time, destroyed and archived. I agree and grant permissionName(Required) First Last Date(Required) MM slash DD slash YYYY Signature(Required)Use your mouse or your finger to sign.Email(Required) Phone(Required)Photo Conditions(Required)What condition is/are the product(s) being used to treat (alopecia, melasma/hyperpigmentation, rosacea, etc.)?
