Carolina Pintos Therapy, PLLC
11777 Katy Freeway, Suite 260 South, Houston, TX 77079
5 Grogans Park, Suite 107, Spring, TX 77380

This form gives Carolina Pintos Therapy, PLLC (the “Company,“ “we,“ “us“) your permission to use photographs, video, and statements about your care in our marketing — including images of your treatment area, images that show your face, your first name, and any testimonial you choose to give. Because we are a healthcare provider, this information is protected health information under HIPAA, and we cannot use it for marketing without your written authorization.

Please read this before signing, and ask us anything that is unclear. Your name and email address are captured electronically when you sign, and the signed copy is filed in your record.

Signing Is Voluntary — and It Does Not Affect Your Care:

Signing this form is entirely your choice. We will not condition your treatment, payment, enrollment, or eligibility for any service on whether you sign it, and we will not treat you differently in any way if you decline. Say no and nothing changes about your care, your appointments, or your pricing.

What You Are Authorizing:

You authorize the Company to photograph, film, and record you, and to use the following in the marketing uses described in Section 4:

Photographs and video of the area of your body being treated, including before-and-after images; photographs and video that show your face; your first name; a general description of the type of service you received; and any written, spoken, or recorded testimonial or review you choose to give us.

We will not publish your last name, your date of birth, your surgeon’s name, your treatment dates, your diagnosis, or any other part of your medical record.

You Can Ask Us to Use Less:

This form sets the outer limit of what we may use — not a requirement that we use all of it. If you are comfortable with images of your treatment area but not with your face, your name, or a testimonial, tell us and we will honor that. Tell the person taking the photographs, or email us at the address in Section 6, and we will frame and crop to exclude your face and will not publish your name or your words.

If you would rather we use nothing at all, do not sign this form. That is a completely acceptable answer and it changes nothing about your care.

Where We May Use It:

The Company may use the authorized materials on its website; on its social media accounts, including Instagram, Facebook, TikTok, and YouTube; in paid advertising, including social and search advertising; in print materials such as brochures, flyers, posters, and in-clinic displays; in email and text marketing to the Company’s patients and prospective patients; and in presentations, training materials, and materials shared with referring providers.

What We Will Not Do:

We will not sell your images, your statements, or your information. We will not alter images in a way that misrepresents your results. We will not put words in your mouth: any testimonial we publish will be your own words, or an edit you have approved.

How Long This Lasts, and How to Take It Back:

This authorization expires five (5) years from the date you sign it.

You may revoke it at any time. To revoke, send written notice to [email protected], or give a signed note to any staff member at either location. Your revocation takes effect when we receive it.

Two honest limits apply. We cannot undo uses we already made before receiving your revocation. And materials already printed, distributed, or published where we do not control removal — a post someone else has shared, screenshotted, or saved, or a brochure already in circulation — may continue to exist. We will stop all future use, remove the materials from the channels we control as promptly as each platform allows, and confirm to you when we have done so.

Re-Disclosure — Please Read This Carefully:

Once we publish materials under this authorization, the people who see them are generally not covered by HIPAA. If the materials show your face or your first name, they can be re-shared, saved, screenshotted, and searched by others, and they are no longer protected by federal privacy law. We cannot control what someone else does with a post after they have seen it. Please weigh this before deciding, and remember that Section 3 lets you keep your face and name out of it while still helping us.

No Payment; No Approval Rights:

Unless we have separately agreed in writing, you will not be paid for these uses, and you waive any claim to royalties or other compensation. You agree that we may edit, crop, resize, and format the materials for presentation, and that we are not required to submit finished materials to you for approval before use.

Ownership:

The photographs, video, and recordings we create remain the property of Carolina Pintos Therapy, PLLC. This does not give us any rights in your medical record beyond what you authorize here, and it does not change your rights to your own health information under HIPAA.

If You Are Signing for Someone Else:

If the patient is under 18, or has a legal guardian or personal representative, that person must be the one to sign. By signing, you confirm that you are the patient’s parent, legal guardian, or authorized personal representative, and that you have authority to give this authorization on the patient’s behalf. All of the choices, limits, and revocation rights in this form apply the same way.

Your Copy:

You are entitled to a copy of this signed authorization. Ask any staff member and we will provide one.

AUTHORIZATION

By signing below, I confirm that I have read and understand this form; that signing is voluntary and my care will not be affected if I decline; that this authorization covers images of my treatment area, images showing my face, my first name, and any testimonial I give; that I understand materials showing my face or name may be re-shared by others and are no longer protected by federal privacy law once published; that I may ask the Company to use less than this form allows, as described in Section 3; and that I may revoke this authorization in writing at any time, subject to the limits described in Section 6. I authorize the Company to use the materials as described above.