TESTIMONIAL Patient Consent

I hereby authorize Obesity Care Group - Dr. Daniel Campos (Centro de Obesidad y Cirugía Laparoscópica S.C.), Obesity Travel Group, and affiliated agencies to use / disclose my:

Photos
Patient Testimonials
Video Testimonials

And I give my consent to be disclosed in any media channel that the company uses for its promotion (website, social networks, promotional videos, industry blogs, medical directories, among others).

Please complete the form below

Name

First Name

Last Name

Email Address

Surgery Performed

Surgery Date

YYYY

Initial Weight

Current Weight

lbs / kgs

lbs

kgs

Consent

Because I have agreed to disclosure and distribution of my testimonial, photo and/or video to the public, I release and hold harmless Obesity Care Group (Centro de Obesidad y Cirugía Laparoscópica SC), its employees and legal affiliates, and Obesity Travel Group from any and all claims for damages of any kind based on the use of my testimonial, video or photograph or any information contained therein. By signing below I agree and acknowledge that I have read and understood the above Release and Consent and agree to all terms described.

I agree

Initials

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature/initials is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature/initials, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature/initials or claim that my electronic signature/initials is not legally binding.

Date

YYYY

Patient Consent ENG

TESTIMONIAL Patient Consent

Please complete the form below

CONTACT US

OBESITY TRAVEL GROUP