We love sharing our patients’ excitement over their new bundles of joy! If you’re interested in being featured on our social media accounts and/or website, please submit the following form and waiver along with a photo of your little one(s).

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.

Photographic material, audio or video recordings may be used for the following purposes: 

• social media
• website development
• physical and digital advertising and marketing materials

By signing this release I understand this permission signifies that photographic materials or video recordings of me may be electronically displayed via the Internet along with any additional information that I provide on the following form.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

I understand and agree that these materials shall become the property of Empire OB/GYN and will not be returned.

I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material.