Media Consent Form Thank you for helping us share your beautiful results with others considering procedures. Name* First Last Date Date Format: MM slash DD slash YYYY I hereby authorize and grant permission to the office of Dr. Francis J. Collini, MD, FACS, PC, located at 1845 Memorial Highway, Shavertown, Pennsylvania 18708 to video record and take photographs of my procedure and/or use my preoperative and postoperative surgical photographs for the education of perspective patients. This would include The Renaissance Center’s website, social media & in house materials. Check whichever applies.*OK to use images that don’t include any identifying marks or characteristics including tattoos, birthmarks, piercings and entire face. If the procedure is done on the face, only that specific section of face would be shown.OK to use my entire likeness.If you select “don’t include any identifying marks” all tattoos, birthmarks, or identifiable characteristics will be blurred or covered before any photographs are shared.I understand and agree that these videos/photographs/media will become the property of Dr. Francis J. Collini, M.D., F.A.C.S., P.C. Should I request copies of these videos/photographs, electronic versions will be made available. I am at least 18 years of age and have read and understand this Video/Photograph release. Signature*Email* NameThis field is for validation purposes and should be left unchanged.