Ronald S. Jacobson
Raymond Y. Tsou
4200 W. Peterson Ave.
Chicago, IL 60646
Vernon Hills Office:
281 W. Townline Rd
Vernon Hills, IL 60061
PHOTOGRAPHIC MEDIA AND/OR SOCIAL MEDIA CONSENT
I hereby consent to the collection and use of my personal images by photography or video recording.
I further acknowledge that Jacobson & Tsou Orthodontics may use my image in media to promote the practice in the future.
I understand that no personal information, such as names, will be used in any publications unless express consent is given.
I also understand that my consent can be withdrawn at any time in writing to Jacobson & Tsou Orthodontics.
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Jacobson & Tsou Orthodontics and its affiliates and agents, to use my image, video and photographic likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet and Social Media sites).
Name (Please Print)
Signature or If Minor, Individual’s Legally Authorized Representative
Relationship to Minor