Photo Release :: Hospice Buffalo

Photo Release Form

Name of Person in Photo/Audio/Video *

Please select *

Patient Community Staff

Address *

Phone *

Please select *

Cell Home Work

Email *

Please complete this section if primary caregiver providing authorization signature below

Name *

Relationship to patient *

Address

Phone *

Please select *

Cell Home Work

Email *

Please Sign

Electronic Signature *

Date *

Internal Use ONLY

Event/Occasion

Name of Hospice Staff obtaining authorization

Title

Department