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35 Jolley Drive Suite 102
Bloomfield, CT 06002
Tel 860.242.2200 Fax 860.242.2212
Marketing Consent for VERJU Laser Therapy
DATE: _______________
Advance Biomedical Treatment Center has requested permission to use information and images from your procedure,
VERJU Laser Therapy, which includes, but is not limited to, my personal health information related to the procedure
(e.g. age, gender, skin type, treatment regimen, etc.); procedure and client descriptions; portrait, picture, likeness;
and my voice. Any or all of which may be used in a recording, videotape, television production or reproduction, sound
track recording, film strip, still photograph, medical research, product development, training or other written
materials or articles for publication purposes, including use on website(s) supported by Advance Biomedical
Treatment Center. Such information and images will become a part of my personal health records and, under certain
circumstances, may be shared or given to third parties as a part of my health records. I will have the ability to review
and access such information and images as a part of my health records and provide corrections to errors I believe
exist. Beyond this, I acknowledge that I have no rights, title or interest in the information and images, including claim
of copyrights.
I consent to photographs and videos being taken only with the consent of my physician, and under such
conditions and at such times as may be approved by my physician. I agree that the photographs and videos shall
be taken by my physician, office staff, or by a photographer approved by my physician.
I hereby grant to Advance Biomedical Treatment Center, its successors, assigns, and anyone acting under its
authority or permission, the right to make originals, copies or derivate works of the information and items
referred to in this Consent Form, where appropriate and to use for any lawful purpose (including publicity and
other trade purposes) throughout the world and reproduce at any time in any form or manner and to copyright
any form or manner capturing the information and items referred to in this Consent Form.
I hereby release Advance Biomedical Treatment Center and its successors from any claim, which I might
otherwise have, as a result of any such use, copyright or publication.
Client name (please print) _____________________________________________________
Signature _______________________________________________ Date __________________