Optional media & testimonial permission

Printable review draft — no online submission or signature collection. Participation in services does not require publicity permission. Nothing is preselected. Final use must identify the specific material and channels, and allow a genuine choice.

Your choices

Client name and date:

□ I decline all photography, recording, and promotional use.

If you wish to permit something, select only what you agree to:

□ Still photographs of me.

□ Video with my image. □ My voice/audio.

□ The specific written testimonial approved below.

□ First name only. □ Initials only. □ Anonymous. □ Full name (write exact name).

Where may the approved material appear?

□ Practice website. □ Instagram. □ Facebook.

□ TikTok. □ YouTube. □ Printed materials.

□ Paid advertising — separate explicit choice, not automatic.

Describe exact images, clips, or testimonial text; approved editing, dates, expiration, and any compensation:

□ I want to approve the final version before any public use.

Limits and withdrawal

No private session details, health information, or sensitive personal story may be published unless the exact disclosure is separately described and expressly permitted. Material must not be edited to change the meaning of what I said. Permission does not authorize sale of my likeness or an implication that I endorse guaranteed health outcomes.

Proposed revocation rule: I may withdraw permission for future uses through the practice's final monitored contact. The practice will stop new use and make reasonable efforts to remove material it controls, subject to agreed terms and applicable law; it cannot guarantee removal of third-party copies, shares, or printed materials already distributed. A response process and contact must be finalized before this form is used.

A private session recording for my personal use requires a separate recording agreement and is not authorized as marketing content here. No permission for a minor is established by this form.

Client signature

Date

Practitioner signature

Date