Photo Release – Heidi Miller Speech

973-358-5665 | 973-525-5191 | admin@heidimillerspeech.com

Release of Photographs/Videos

I give Pediatric Speech Language and Feeding Therapy with Heidi Miller Speech and Associates, permission to photograph and/or record my child, to release for use in research, to show progression of his/her skills, Pediatric Speech Language and Feeding Therapy with Heidi Miller Speech and Associates’ Website, Social Media, Advertising Materials, or to the therapist’s discretion.
Your Name
First Last
Child's Name
First Last
Your email address