Permission to Record

Recording Permission

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PERMISSION TO PHOTOGRAPH AND/OR RECORD AUDIO AND VIDEO

Patient/Guardian Name(Required)

I, the above named individual hereby authorize The Neurology Center of Fairfax/ Sleep Diagnostic and Treatment Center, or their representative, to take photograph(s) and/or record audio and video of the named individual below.

Name of Patient(Required)

I understand that such photograph(s), audio recording(s) and/or video recordings may be used for clinical or educational purposes, or in the event of legal action. The sleep center and directors of The Neurology Center of Fairfax, Ltd. and its duly appointed representatives are hereby released without recourse from any liability arising from obtaining and using such photograph(s), audio recording(s) and/or video recordings.

The undersigned also hereby transfers and assigns to The Neurology Center of Fairfax/ Sleep Diagnostic and Treatment Center the right to copy the materials in whole or in part. No use of the material for educational purposes will identify me by name.

Patient/Guardian First Name(Required)

Patient/Guardian Last Name(Required)

Guardian's Relationship to Patient

Date(Required)

Email(Required)

Enter Email Confirm Email

Witness

Date

Rev 9.29.2022