Magic Post Op - Client Consent + Intake

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Section 1

Media Release Agreement

Choose how you want to participate in photo or video content.

Media Release Agreement

I consent to MJS using my photos/videos with full identification (name, face, voice, likeness) for advertising and promotional purposes.I consent to MJS using my photos/videos with anonymity (face blurred, no name, no tattoos/piercings visible, voice altered).I do not wish to participate in the media content at all (this includes any photos, videos, or voice recordings).

Section 2

Client Consent + Waiver

Participant demographics and contact details.

Last Name

First Name

Middle Initial

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Fax

Used for appointment confirmations

Date of Birth

Company Name

Occupation

Age and Legal Capacity Acknowledgment

I acknowledge that I am at least 18 years of age and have the capacity to enter into this agreement.

Section 4

Acknowledgement + Signature

Confirm and sign electronically.

Participant Name

Type your full legal name

Date

Participant Signature

Use your finger on touch screens or your mouse on desktop.

I have read and understood this Media Release, Client Consent Form, Waiver of Liability, Assumption of Risk Agreement, and Client Intake Form, and agree to all terms. My typed name and drawn signature above constitute my legally binding electronic signature.