OSMA Photo and Video Release

Thank you for providing photos and/or videos to use in promotional materials and social media platforms.

Photo Release

For consideration which I acknowledge, I grant to the Ohio State Medical Association (OSMA) the absolute and irrevocable right and unrestricted permission concerning any photographs/videos taken of me or in which I may be included with others, to use, reuse, publish, and republish the photographs/videos in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, and for any purpose whatsoever, specifically including illustration, promotion, art, editorial, advertising, and trade, without restriction as to alteration. I release and discharge OSMA from any and all claims and demands that may arise out of or in connection with the use of the photographs/videos, including without limitation any and all claims for libel or violation of any right of publicity or privacy.
This authorization and release shall also inure to the benefit of the heirs, legal representatives, licensees, and assigns of OSMA, as well as the person(s) who took the photographs/videos. I am a legally competent adult and have the right to contract in my own name. I have read this document and fully understand its contents. This release shall be binding upon me and my heirs, legal representatives, and assigns.
By checking this box, I agree to the above release.
First Name
Last Name
Email Address

Upon submission of this form, photos and videos can be supplied anytime to OSMA at comm@osma.org. Form only needs to be submitted once and will be kept on file indefinitely.
- Name of Doctor(s) in photos/videos
- Name and location of practice
- Your Facebook page, LinkedIn account or other social media link
- How has OSMA most benefited you or your practice?
- Anything else you'd like to share about your practice (story, recent accomplishment, celebration, etc.)
Due to privacy laws, do not send any photos or videos that include patients.
   - denotes required fields