The Fertility Center of Las Vegas

We look forward to seeing you very soon and would appreciate if you would complete the Photo/Video Release Form.

General Photography & Videography Release Form


  • General Marketing Release

    I/We, the undersigned on my/our own behalf and on behalf of any minor child or infant hereby irrevocably consent to and authorize the use, modification, distribution, reproduction, and publication by The Fertility Center of Las Vegas and/or anyone authorized by The Fertility Center of Las Vegas of any and all images, voice recordings and/or video (in whole or in part and into any medium), written review/testimonial/etc which have been obtained of me and/or my family including my children for any purpose for all perpetuity and for no compensation or consideration. As such, I/We agree to hold The Fertility Center of Las Vegas and its officers and employees free and harmless from any and all liability arising out of the use of this photograph, image, audio, video, or written review, testimonial, thank you note, survey and/or letter and subsequent publication or broadcasting. I authorize and request The Fertility Center of Las Vegas to speak with (and be contacted by) any authorized writer, marketing/PR/media company, photographer, videographer, or similar professional about the medical services, diagnosis and treatment received. I also hereby release, discharge, and agree to save the practice, the doctor(s) and staff from any liability for any misstatements, typographical errors, grammatical errors or misspellings, whether intentional or otherwise, that may occur or be produced in the creation of said reviews, surveys, testimonials, comments, thank you notes and/or letters created by the patient named below, or in any processing needed for the completion of the finished product. I agree I am at least 18 years of age and release any and all claims which I have or may have for infringement of copyright, invasion of privacy, liability or defamation, breach of contract, or any other cause of action arising out of production, distribution, broadcast, publication, or exhibition of any other use of my interview. This agreement is effective until The Fertility Center of Las Vegas has received written notification otherwise and will include all immediate family members including partner/spouse and children.
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    NameDate of BirthRelationship to Patient 
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  • This agreement is effective until The Fertility Center of Las Vegas has received written notification otherwise.