PHOTOGRAPHIC AND NEWS CONSENT

The undersigned hereby grants to Cornerstone Clinic for Women permission to take photographs, motion pictures and/or videotapes ("Photographic Materials") of the below named patient and to use his or her name in connection with any such Photographic Materials:

The undersigned hereby permits Cornerstone Clinic for Women and its agents to use and distribute such Photographic Materials together with the name of the below named patient as often as desired for any lawful purpose, in accordance with applicable law. The undersigned hereby waives all rights of prior inspection or approval and releases Cornerstone Clinic for Women and its agents from any and all claims or demands that may exist on account of the lawful use, disclosure or publication of such Photographic Materials as described herein.