Letter of Consent To Use Patient Information

This form is to request your permission to share you/your child’s photo/video and/or success story on The Center for Vision Development, P.A.’s website and/or social media page(s) (www.austinvisiontherapycenter.com, Facebook, etc).

By law we are required to have your written permission on file to use any information about you/your child.

No personal/identifying information will be posted other than the images/photos that you have authorized us to use and your/their first name.

If you/the parent/guardian, wish to rescind this agreement at any time, you may do so in writing by delivering proper notice to our office. We will respond as quickly as possible to make the necessary changes that you have requested..

__________________________________________________________________________________________

I grant The Center for Vision Development, P.A. permission to use photo(s)/video(s) and/or success story of me/my child on CVD’s website and/or social media pages (www.austinvisiontherapycenter.com, Facebook, etc). This authorization will remain in effect until consent is properly rescinded via written request and received by our office.

Consent is given to use photo(s)/video(s) and success story (check one):

with first name

without first name

I decline this request to use my/my child’s information.

Patient’s Name (please print):

First Last

Date of Birth:

Parent/Guardian’s Name (please print):

First Last

Patient’s/Parent’s Signature:

Date