I understand that I may withdraw this authorization for future use by providing written notice to Insights Wellness Center, LLC. Withdrawal will not affect materials that were already published, distributed, or otherwise used before the withdrawal was received. Yes(Required) Yes, I authorize Insights Wellness Center, LLC to photograph, video record, and/or audio record me and to use those materials for educational, informational, promotional, website, social media, event, and related communications. No, I do not authorize this use. Electronic Signature(Required)Typing my name electronically and submitting this form serves as my electronic signature and confirms the authorization choice I selected above.Date(Required) MM slash DD slash YYYY Email(Required)
