Consent to filming and taking pictures

Patient Full Name(Required)

First Name Last Name

Patient's confimation

I agree that:(Required)

By signing this consent, I confirm that I have been explained clearly, that my image filming and/or taking pictures before and after the procedure will be publish in JSC "Vivamedicus" (NEWMAN Clinic) websites and social media.

I agree/disagree (unnecessary to be deleted), that filmed and/or photographical material with my image will be managed, stored and used by JSC „Vivamedicus“ (NEWMAN Clinic) for marketing purposes and without separate consent of me at the discretion of JSC „Vivamedicus“ (NEWMAN Clinic) would be made public in mass media, in publications, promotional announcements or training purposes published. By giving this consent to film and/or take pictures of my image, confirm that I do not charge any remuneration for fixing my image:(Required)

Agree
Disagree

I agree that:(Required)

I was also explained that if I have any questions in future or will want to cancel this consent, I will be able to contact with representatives of JSC „Vivamedicus“ (NEWMAN Clinic) and change my decision at any time.

I agree that:(Required)

I have read (it has been read to me) the text of this consent to filmmaking and photographing. I have understood the verbal explanations of this consent and this text.

Email

This field is for validation purposes and should be left unchanged.

Call us on

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Part of the Newman Clinic

Patient’s consent to filming and taking pictures

Patient's consent to filming and taking pictures

Patient's confimation