Consent for Use Breast Augmentation Photos

Please print, sign, scan and email, or fax this with your pictures.
You may fax to 208-979-8162
or Email to BodyWurks@Yahoo.com

 I have agreed to contribute to the owner of the Breast-Implanst.ws, pictures of my breasts before and after breast surgery.  I authorize Breast-Implants.ws  to display these photos on  Breast-Implants.ws for the purpose of providing potential patients with information to help them arrive at an informed decision. .  I also acknowledge that The Diamond Matrix Group, L.L.C. is the entity that owns the website and hereby further authorize The Diamond Matrix Group, and its staff, to use my pictures. I  release The Diamond Matrix Group and Breast-Implants.ws (Releasees) as follows.

I release the Releasees from any claim by me, my spouse, my children, or anyone claiming on my behalf as successor, assign, beneficiary or heir, for the use of my name or pictures as set forth herein, and agree to permit Releasees to use my name or pictures for any purpose required or desired by the Releasees in promotional publications, advertising, educational presentation, broadcast, cablecast, Internet presentation, or any purpose sponsored by Releasees and their agents, successors, assigns, principals or subsidiaries. This Release shall also extend to the staff of The Diamond Matrix Group , principals and property.   I further hereby release the Releasees from any liability for the distribution of the my pictures, Internet publication, and also release all rights in and to any claim of copyright, trademark, trade dress, or other intellectual property or other rights. I also understand I will receive no royalties, commission or any payment whatsoever in connection with the use of my pictures. I understand that I will have my email address entered into the mailing list for photo gallery members.  This mailing list will remain private, and will only be used by The Diamond Matrix Group for occasional gift certificate drawings.  Entry into these drawing will be free of charge, and only open to those members that have submitted pictures for educational purposes.

I understand that significant changes need to be made to Breast-Implanst.ws when photos are added, and to remove them from the website would create logistical dilemmas , therefore, agree to allow the use as set forth herein, indefinitely. I understand that photos will not be returned. I also understand that all photos will be altered to include pictures of only the shoulders down.

Name:

Address:

Phone Number:

Email Address:

Signature:                                                                                   

Date:

Check One:
 ___Use my first name when displaying photos;
 ___ Use my email address when displaying photos (You will be provided with a web based yourname@breast-implants.ws email address. This address will have forwarding of all inquiries to your personal email address, which will not be published.;
___ Use both first name and email;
___Keep photos anonymous