(2022) Photograph and Release Photograph Consent Form​


Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Fax: 623.471.5180




I consent to the taking of photographs and/or videos by Dr. Bradley K. Becker, associates, or representatives of myself or parts of my body in connection with the procedure/surgery intended to be performed. I understand that photographs may be taken before, during, and/or after my procedure or surgery as a routine part of my medical care and that all photographs and/or videos will be kept strictly confidential.




I authorize the use of my photographs and/or videos in the formats listed below. I waive any right to inspect or approve the finish product, advertising or other copy that may be used in connection with the options below. I understand that I will never be identified by name in any use of these photographs and/or videos, and the photographs/videos taken will only include areas of the body pertaining to or related to my specified procedure. However, in some circumstances the photographs and/or videos may include or portray features which may make my identity recognizable.


Please initial or check YES or NO for each item below:

For our office photo album for prospective patients
For our website for prospective patients
For print advertisements or television
For social media (i.e., Facebook, Instagram, etc.) for prospective patients or educational purposes.

I understand that all rights to photographs and/or videos taken of me pertaining to my procedure and any claim I may have relating to such use in publication, including any claim for payment in connection to the distribution and/or publication of said photographs and/or videos, are released and discharged to Dr. Bradley K. Becker, associates, and representatives. This consent may be revoked at any time with written consent.


I certify that I have read the above Authorization and Release and fully understand its terms.

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