Photo Video Release Form Photo/Video Release Form Name(Required) First Last Clinic Location(Required)Home InfusionAiken, SCAnderson, SCAsheville, NCBeaufort, SCBirmingham, ALCharleston (West Ashley), SCCharlotte, NCColumbia (Northeast), SCConcord, NCDaphne, ALDothan, ALEvans, GAFayetteville, NCFlorence, SCGreensboro, NCGreenville, NCGreenville, SCHickory, NCHolly Springs, NCHuntsville, ALJacksonville (Orange Park), FLJacksonville (St. Johns), FLLawrenceville, GAMidlothian, VAMontgomery, ALMount Pleasant, SCMyrtle Beach, SCOkatie, SCPanama City, FLPawleys Island, SCRaleigh, NCRock Hill, SCSavannah, GASpartanburg, SCStockbridge, GASummerville, SCSumter, SCSupply, NCWest Columbia, SCWinston-Salem, NCEmail Photo/Video Release(Required)I grant permission to Palmetto Infusion/AccuRX and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Palmetto Infusion/AccuRX and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation. I agree to the above statement. Enter!