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Patient Name _______________________________________________________

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I hereby consent to, and authorize the use by Alexa Menard of the specified Microblading photographs and/or video; that is, photographs taken before, during, and after my Microblading procedure.

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I understand that my identity will be protected and neither my full face nor my name will be used in conjunction with the photographs and/or videos.

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Alexa Menard has explained that all the photos and/or videos will be clinically appropriate and tastefully presented.

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I have agreed on the photographs that Alexa Menard requests to be used and it is understood that these photos may be used on Alexa Menards website, social media accounts (Website, Facebook, Instagram, Twitter, SnapChat), and in-office for demonstrational and promotional purposes. I understand that I am not entitled to compensation for these photographs being used.

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Should I desire to revoke permission for their use in the future, I understand that I must notify Alexa Menard in writing and allow 30 days to accomplish this removal.

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I now release Alexa Menard all my personal rights and objections I have or may have to the above described uses of my photographs and/or videos. I have entered into this release freely or voluntarily, and agree to be bound thereby.

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_____________ DATE

______________________________________________ PATIENT SIGNATURE

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