Health Wealth Safe Media Release & Consent Form

Use & Release:

  1. I grant Health Wealth Safe Inc., and parties designated by Health Wealth Safe the irrevocable right to use the name, likeness, image, voice, appearance and/or performance as captured by photographic, audio and/or video means (the “Product”) for release and/or reproduction in any medium for any legal purpose, including but not limited to social media, promotion, editorial, advertising, education, training, illustration, art, and general trade. 


  1. I acknowledge that I have no interest or ownership in the Product or the copyright in the Product, and that any use of the Product may be  made without compensation or notice.  I waive any right to inspect, approve, and/or otherwise control the use of the Product. 

Acknowledgment and Authorization (by signing, you agree to the following):

  1. I hereby authorize Health Wealth Safe Inc. to photograph my practice, employees, and grounds, take motion pictures, and take video footage, for all media purposes.  
  2. I authorize the use of any such photographic or electronic reproductions of my practice for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Health Wealth Safe 
  3. I understand that the practice, and the location may be identifiable from such photographic or electronic reproduction.

Right to Privacy  

I acknowledge that names and  the practice  may be revealed in the product or by descriptive text or commentary. However, Health Wealth Safe may not  publish my address, telephone numbers, or email address with the product without my permission. 

Leave this empty:

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Signed by Darryl Lewis
Signed On: October 22, 2020

L Brand Creations
Signature Certificate
Document name: Health Wealth Safe Media Release & Consent Form
lock iconUnique Document ID: ec1e2bc3ec9cd8dbb6f90445f4f95fa7545c7b18
Timestamp Audit
October 22, 2020 8:15 am -05Health Wealth Safe Media Release & Consent Form Uploaded by Darryl Lewis - IP