Your email address will not be given out or posted with your photo. We will use it if we need to contact you regarding your photo.

Your phone number will not be given out or posted with your photo. We will use it if we need to contact you regarding your photo.

I hereby grant Fertility & Surgical Associates of California, Inc. permission to use my written likeness in any photograph, video or other digital or print reproduction (the “Materials”) in any and all of its publications, including websites, without payment or any other consideration. I understand and agree that the Materials will become the property of Fertility & Surgical Associates of California, Inc. and will not be returned. I hereby authorize Fertility & Surgical Associates of California, Inc. to edit, alter, copy, exhibit, publish or distribute the Materials for purposes of publicizing its programs or for any other lawful purpose. I understand that the information disclosed, or some portion thereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I further understand that, because Fertility & Surgical Associates of California, Inc. is not receiving the information in the capacity of a health care provider by HIPAA, the information described above may no longer be protected by HIPAA. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, but if I do so it won’t have any effect on any actions taken prior to my revocation. I certify that I have read the above Authorization and Release and fully understand its contents, meaning and impact of this release.