Photo Consent Form

We would love to share your picture with our family of patients. Due to HIPAA privacy laws, we need signed consent to do so. Please take a second to sign the form below. Your electronic okay allows us to use the picture for marketing purposes, including Facebook, our website and other marketing materials.

You are authorizing Jackson Regional Women’s Center to use images and/or video of yourself or your child. The images may also be …

  • Placed in your medical record
  • Electronically emailed to your treating health professional
  • Used by physician for education and training
  • Used in paper or electronic health publications
  • Used in a commercial broadcast use

This consent involves no financial consideration to either party. Thank you.


Thank you for your submission, we'll be in touch as soon as possible.
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