CONSENT TO TAKE AND PUBLISH PHOTOGRAPHS

The undersigned hereby authorize Advanced Wellness West Valley Medical Group and Allen Lawrence, M.D. and or staff, with my full consent and permission, to take personal and group photographs and video and to use these photographs as and/or video for publication in brochures, handouts, newspapers, magazines, social media, websites and other unnamed publications.
This authorization permits Advanced Wellness West Valley Medical Group and Allen Lawrence, M.D. to photographs, videos and/or interview me during these events.

I __________________________________________________ give permission for said
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purposes stated above to have my likeness, video and photograph(s) and/or statements made by
me at the time of an interview to be taken and used in or as part of an article and/or advertisement or to be published as news, commercials and/or entertainment information, advertising or public relations material in one or all of the following: publication in brochures, handouts, newspapers, magazines, social media, websites and other unnamed publications.
I agree that said articles or publications and all photographic negatives and prints and video will remain the property of Advanced Wellness West Valley Medical Group and Allen Lawrence, M.D.
Signing of this consent/release provides consent to Advanced Wellness West Valley Medical Group and Allen Lawrence, M.D. to interview, video and/or photograph and gives permission to use all said photographs, video and information provided by the above stated person in one or more articles to be published in one or more of the above stated instruments. The undersigned does not authorize any other use to be made of these photographs.
No compensation is offered in return for this service other than our appreciations and
thanks to you for participating and for the opportunity to see and read the article and/or commercials that may be published. We make no guarantee or warranty that any specific photos taken will be published.

DATE_______________________________
SIGNATURE_________________________________________
GUARDIAN FOR___________________________________________
STREET ADDRESS_____________________________________________
CITY_________________________________________________
STATE and ZIP__________________________________