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Social Media and Website Consent
Social Media & Website Photo and Consent Submission
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Consent
(Required)
I grant permission to AFRM for website and social media purposes
I hereby grant ArkLaTex Fertility and Reproductive Medicine (AFRM) permission to share my photos on their AFRM web, calendar and social media sites to include text, pictures, or videos of myself and/ or my child/ children. I understand that I have the right to request, in writing, the removal of the information, and AFRM will have 30 days from receipt of this request to comply with my wishes. I understand this authorization will remain in effect until I request the removal of the information. I understand this authorization is voluntary. Treatment, payment, enrollment, or eligibility for benefits (as applicable) will not be conditioned upon my signing this authorization form. Any photos submitted become the property of AFRM to be used or disposed of as it deems appropriate. Nothing in this agreement shall be construed as creating an express or implied contract of solicitation for payment or treatment of services.
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(Required)
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Day
Year
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Max. file size: 50 MB.
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