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Photography | Video | Privacy Notice
For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Owensboro Atlas Center, or anyone authorized by Owensboro Atlas Center, of any and all photographs/videos which you have this day taken of me, for the purpose of promotional TV and/or print ad whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Owensboro Atlas Center, solely and completely. Any information voluntarily provided by a practice member shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also waived to the extent of the information pertinent to the promotion material only. All other unrelated practice member information shall remain private and protected (according to the Health Information and Privacy Act laws.)
Your printed name below represents your signature of consent for Owensboro Atlas Center to take and utilize photos and videos as stated above.