IMAGE CONSENT & RELEASE 

I, _____________________________, hereby authorize my health care provider, ___________________, or any of my health care provider’s staff, to take photographs and/or videos (“Images”) of me and to provide those Images to Inner Archways, LLC to be shared on its application Edvyce, a software platform designed by clinicians for clinicians to exchange clinical questions, review images and data, and provide educational feedback to one another.  I understand that my Physician will remove any identifying information or characteristics (such as full face photos) from all Images and will not disclose my name or any other Protected Health Information (“PHI”) as defined under the Health Insurance Portability and Accountability Act (“HIPAA”) without my prior written authorization. 

I understand that these de-identified Images may be used for educational purposes in lectures, demonstrations, advertising (including on a website or in newspapers or magazines) and professional publications (including magazines and journals). I further understand that if the photographs and/or videos are used in any publication or as a part of a demonstration, neither my name nor any other identifying information will be used.  I understand that I will not receive, and will not be entitled to, any compensation, financial or otherwise, for the use of these Images. 

I specifically consent to the digital manipulation of the Images, including, without restriction, changes or alterations as to color, size, shape, perspective, context, foreground or background, especially where they may further help in removing identifiable features.  I also consent to the use of any published matter in conjunction with the Images.  I hereby waive any right that I may have to inspect or approve the Images or the finished product or products in which the Images may be used or may appear. 

I further acknowledge that Company is under no obligation to use the Images for any marketing or other promotional purpose or otherwise, and that I will not be entitled for any reason to terminate or to rescind this Consent and Release or to impair or restrain any of Company’s rights as set forth in this Consent and Release. 

I hereby release, discharge and agree to hold harmless Inner Archways, LLC, and its directors, officers, employees, licensees, successors and assigns (individually and collectively, “Company”) and my health care provider and my health care provider’s staff, from any claims, damages or liability that I (or anyone claiming by or through me) may ever have in connection with the taking or use of the Images, including, but not limited to, any claims for violation of any right of publicity or privacy.  

This Consent and Release will be governed by the laws of the Commonwealth of Pennsylvania, without effect given to conflict of laws principles, and the courts located in Montgomery County, Pennsylvania, will have exclusive jurisdiction over any disputes arising from or related to this Consent and Release.  This Consent and Release supersedes all prior discussions, negotiations, understandings, and agreements (whether oral or written) between me and either my Physician or Company regarding the Images, and may not be changed except by written agreement signed by Company and me.  I have not been forced or induced to enter into this Consent and Release by any representation or promise that is not contained herein.  I have read this Consent and Release prior to signing it, and I understand its contents and agree to the terms hereof.

By signing below, I certify that I am at least 18 years of age and competent to sign this release, or, if I am under age 18, my parent or legal guardian has signed below.  I have read this release before signing, I understand its contents, and I freely accept its terms.  My permission and release have been given without coercion or duress of any kind. 

I understand that this Consent and Release will be binding upon me and my heirs, legal representatives, successors and assigns. 

Signature:                                                                                  Date: ___________________

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