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Photo/Video Release Form


                                                   Video/Photo Release Form


   I, _____________________________________________________(please print), grant permission to DFW Orthotics and Prosthetics and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release DFW Orthotics and Prosthetics and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.


I acknowledge that I am
I have read the Photo/Video Release Form and Give Consent
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