Release and Consent Form

PHOTO, VIDEO AND SOUND RECORDING RELEASE, HOLD HARMLESS AND CONSENT FORM

By signing this Photo, Video and Sound Recording Release and Consent Form, you are irrevocably giving permission to Jessie Rogers-Herbert, Carl Herbert and their agents, employees, successors, licensees, and assigns to take and use photographs, video, or sound recordings of you for the following projects: patient testimonials; teaching and research as well as presentations for YouTube or otherwise.

This is completely voluntary and up to you. Your consent to the use of the photographs, video and sound recordings and your image, likeness, appearance, and voice is for forever. You will not receive compensation for the use of your image, likeness, appearance, and voice now or in the future.

Jessie Rogers-Herbert, Carl Herbert 5th & Overland may use the photographs, video and sound recordings containing your image, likeness, appearance and voice in any manner or media, including use on web pages. The photographs, video and sound recordings may be used for any educational, institutional, scientific, or informational purposes whatsoever.

Jessie Rogers-Herbert, Carl Herbert, 5th & Overland have the right and may allow others to copy, edit, alter, retouch, revise and otherwise change the photographs, video and sound recordings at their discretion.

All rights, title, and interest in the photographs, video and sound recordings belong solely to Jessie Rogers-Herbert, Carl Herbert 5th & Overland. You further give permission to Jessie Rogers-Herbert, Carl Herbert 5th & Overland to use your name, biography, and any other events, or other material in or in connection with any such uses of the photographs, video, and sound recordings. I understand and agree to the conditions outlined in this photograph, video and sound recording release hold harmless and consent form. I irrevocably give consent to Jessie Rogers-Herbert, Carl Herbert 5th & Overland and officers, agents, employees, successors, licensees, and assigns forever to make use of my image, likeness, appearance, and voice in photographs, video and sound recordings as described above I acknowledge that I am fully aware of the contents of this release and am under no disability, duress, or undue influence at the time of my signing of this instrument.

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