Sports Medicine Ultrasound Photo and/or Video Release

Purpose of Consent: By signing this form, you are hereby consenting to allow Sports Medicine Ultrasound to use and disclose your photos and/or videos and you acknowledge that they may be distributed to the public.


I hereby authorize Sports Medicine Ultrasound to use my photos and/or videos in its training and media/public relations efforts. I understand that I am providing the photos or videos to Sports Medicine Ultrasound and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and provincial regulations, including the Personal Information Protection and Electronic Documents Act (PIPEDA).

I waive the right of prior approval and hereby release Sports Medicine Ultrasound from any and all claims for damages of any kind based on the use of my photos and/or videos. By signing below, I agree and acknowledge that I have read and understood the above Release and agree to all terms described. I am of legal age and freely sign this Consent to Release my Patient Testimonial and other media I provided to the clinic.


Full Name
I have read, understand, and agree to the Sports Medicine Ultrasound Photo and/or Video Release