Media Release Form – Dr. Karen Doherty x AESTHETICARE"*" indicates required fieldsParticipant Information ("I and You")Name* First Name Last Name Address* Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Company Information ("Company"):AESTHETICARE, a division of Ferndale Pharmaceuticals Ltd Unit 740, Thorp Arch Estate, Wetherby, West Yorkshire, LS23 7FX, United KingdomClinic Information ("Clinic"):Dr. Karen Doherty, 34 Darville Road, London, N16 7PS, United KingdomOverviewThis Media Release Form relates to skin treatments provided to You by the Clinic. It grants the Company [and the Clinic] the rights to use information and images generated by the Clinic in relation to your treatment, your treatment patient journey, and the associated use of the dermo-cosmetic skincare products supplied by the Company. The Clinic is responsible for the treatment you receive, and the Company is responsible for supplying the dermo-cosmetic products used to enhance your skin and the results of your treatment.The objective is to use the information and images in an informative and educational manner to help the Company and the Clinic explain to others how the dermo-cosmetic products can enhance skin and treatment results.Consent and AgreementI, the undersigned, hereby grant the Company [and the Clinic] the following rights: Permission to Use Content and Images:I consent to the use of my before and after photos, treatment journey details, testimonials, and any other related content (collectively referred to as “Content”) created by the Clinic in relation to the use of dermo-cosmetic skincare products supplied by the Company. Usage Rights:I grant the Company [and the Clinic] the right to use, reproduce, distribute, and display the Content in various media formats including, but not limited to, relevant websites, social media platforms, marketing materials, promotional campaigns, and educational materials. Duration:This consent is granted indefinitely unless otherwise revoked by You in writing. No Compensation:I understand that I will not receive any monetary compensation from the Company for the use of the Content. Acknowledgement of Treatment Responsibility:I acknowledge that the Clinic is solely responsible for the administration and the outcomes of the treatments provided by them and related to this media release form.Acknowledgement and ReleaseBy signing below, I acknowledge that I have read and understood the terms of this Media Release Form. I understand that my participation is voluntary and that I can revoke my consent at any time by providing written notice to the Company and the Clinic.Participant SignatureSignatureDate MM slash DD slash YYYY Witnessed BySignatureName First Last Date MM slash DD slash YYYY
