photographic / video release form

At Urban PetRx, we love including our patients and clients on social media! Please complete the form below for consent.
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Photographic / Video Release Form

Please fill out this form completely and accurately if you would like to consent to our photographic and video release. You may also download the form by clicking the button below.

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Urban PetRx Photographic/Video Release & Authorization for Marketing

I, the undersigned, hereby agree to this Video and Photographic Release and Authorization for Marketing (“Release”). I voluntarily authorize Urban PetRx to video and audio record and photograph me and my pet in any manner and to disclose and use video and audio recordings and photographs of me, my first and last names, age, and profession (collectively “Media-Related Information”) for marketing purposes on social media, including Facebook, Instagram, Twitter, YouTube, Medium, and the website of Urban PetRx (collectively “Social Media”).

I acknowledge and agree that I may revoke this authorization at any time by notifying Urban PetRx in writing. However, once the Media-Related Information is published on Social Media, Urban PetRx has no control over subsequent third-party redisclosure; thus, the Media-Related Information cannot ever be completely removed from Social Media or the Internet generally. This means that even if I revoke this consent, Urban PetRx will be unable to completely remove the Media-Related Information. Such revocation will only apply to future disclosures.

I further acknowledge and agree that I will not receive compensation for signing this document, being video and audio recorded or photographed, or for any use of the Media-Related Information; that I have no right to inspect or approve the Media-Related Information prior to its disclosure on Social Media; and that after I sign this document, the Media-Related Information will no longer be protected by medical privacy laws.

I hereby grant Urban PetRx the right and permission to use the Media-Related Information to reproduce, edit, exhibit, project, display, copyright, publish, in whole or part, on Social Media. I hereby indemnify Urban PetRx against any damages, losses, liabilities, judgments, costs, or expenses (including reasonable attorney fees and costs) arising from any third-party claims that relate to the of the Media-Related Information.

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