This photographic release pertains to photographs taken during the following treatment:


I, (print name) , voluntarily consent to the copyright, publication and use of my picture and likeness by Liza Glickman, affiliates, successors, and assignees.

By signing this form, I am allowing Liza Glickman, affiliates, successors and assignee to disclose photographs taken of me before, during, and after treatment.

Photos can be used for (Please initial either yes or no on each line):
  • Research, educational informational purposes: Yes No
  • Publications in a medical journal and /or textbook: Yes No
  • General advertising, publicity, or promotional purposes: Yes No

I hereby release Liza Glickman from any claim, demand, cause, action, or proceeding of whatever nature arising out of publication and distribution of the said photographs in accordance with the terms of this release. This release also includes affiliates, successors, and assignees 0f Liza Glickman. I also understand that I can revoke (or take away my permission to allow Liza Glickman to disclose photographs of me at any time by sending a letter to Liza Glickman telling her not to disclose photographs of me to affiliates, successors, or assignees of Liza Glickman. If I send a letter saying that I revoke my authorization, Liza Glickman’s Director will not disclose any more photographs of me after he or she receives the letter. However, the Director will not need to return any photographs disclosed prior to his or her receipt of the letter.

I understand that once my photographs have been disclosed to Liza Glickman, affiliates, successors and assignees the photographs will no longer be protected by federal privacy laws. However,Liza Glickman’s affiliates, successors, and assignees will not use the photographs except as permitted on this authorization form. I understand that I will be given a signed copy of this form.

I understand that once my photographs have been disclosed to Liza Glickman, affiliates, successors and assignees the photographs will no longer be protected by federal privacy laws. However,Liza Glickman’s affiliates, successors, and assignees will not use the photographs except as permitted on this authorization form. I understand that I will be given a signed copy of this form.

  • Use your mouse to sign here