Social Media Consent Form

I hereby grant permission to The Piedmont Equine Practice, Inc. to use images of myself, (print name below) and my pets. By granting permission, I affirm I am 18 years of age or older.
Such use includes the display, distribution, publication, transmission or otherwise use of photographs, images and/or videos taken for use in materials that include, but may not be limited to, printed materials such as brochures, newsletters, videos, and digital images used on The Piedmont Equine Practice, Inc.’s website and social media, such as Facebook.
Permission
- I grant permission for the use of photos of myself and my pets to be used
- I deny permission for the use of photos of myself and my pets to be used
Signature
Date (MM/DD/YYYY)
Date Format: MM slash DD slash YYYY
Please return this form to The Piedmont Equine Practice, Inc. Please notify The Piedmont Equine Practice, Inc. in writing if you would like to withdraw your permission for the use of images at any time. If a copy of this signed form is not provided, please request a copy from The Piedmont Equine Practice, Inc.