Photo Consent Form

We would love to share your picture with our family of patients. Due to HIPAA privacy laws, we need signed consent to do so. Please take a second to sign the form below. Your electronic okay allows us to use the picture for marketing purposes, including Facebook, our website and other marketing materials.

You are authorizing Jackson Regional Women’s Center to use images and/or video of yourself or your child. The images may also be …

  • Placed in your medical record or future treatment
  • Electronically emailed to your treating health professional
  • Used by a physician for education and training
  • Used in paper or electronic health publications
  • Used in a commercial broadcast use
  • Available for marketing materials

The photogrphy that a patient brings to the office for public display is also included in this consent. JRWC's Facebook page will display your child's picture once this consent is signed and dated if you send photos to our Facebook page.

Such photographs, ads, brochures and other materials sent by a patient will become the sole and separate property of JRWC, or the media preparing them. This consent involves no financial consideration to either party. By sending in your information, below, you are confirming that you understand this consent form. Thank you.

Thank you for your submission, we'll be in touch as soon as possible.
Your Information