Vivire Wellness may need to photograph and/or record you to document a medical condition, help with diagnosis and/or treatment of a condition, and/or to help plan the details of a treatment Photographs and/or recordings taken for these clinical reasons do not require your written permission. Your provider does need your written permission to use your photographs and/or recordings for the non-clinical reasons below.

I consent to photographs and/or video recordings under the following conditions:

• Copies of the photos, videos, and/or films may be released to me if I ask for them.

• I can refuse to have photos and/or video taken without any change in my patient care at Vivire Wellness.

• I understand and agree that although my name will not be used, it may be possible to identify me from a photo and/or video.

• I understand that once released outside of Vivire Wellness, Vivire Wellness does not have control over the photos or videos.

Revoking Permission: This authorization has no expiration date; however, I may revoke it at any time by writing to Vivire Wellness 5599 University Dr #103, Davie , Fl 33328

• I must state in writing that I no longer give Vivire Wellness 5599 University Dr #103, Davie , Fl 33328( consent for a photo(s) and/or video(s) or for the use of any photo(s) or video(s) . I have read and understand the information. I hereby release Vivire Wellness, its personnel, and any other persons participating in my care from any and all liability that may or could arise from the taking or unauthorized use of such photographs and/or video recordings.