Media Release Form – Dr. Karen Doherty x AESTHETICARE

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Participant Information ("I and You")


Company Information ("Company"):

AESTHETICARE, a division of Ferndale Pharmaceuticals Ltd
Unit 740, Thorp Arch Estate,
West Yorkshire,
LS23 7FX,
United Kingdom

Clinic Information ("Clinic"):

Dr. Karen Doherty,
34 Darville Road,
N16 7PS,
United Kingdom


This 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 Agreement

I, the undersigned, hereby grant the Company [and the Clinic] the following rights:

  1. 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.

  2. 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.

  3. Duration:

    This consent is granted indefinitely unless otherwise revoked by You in writing.

  4. No Compensation:

    I understand that I will not receive any monetary compensation from the Company for the use of the Content.

  5. 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 Release

By 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 Signature

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Witnessed By

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