Please enable JavaScript in your browser to complete this form.
Patient Name

I consent for photographs and/or video images to be taken of me by Anodyne Pain & Wellness Solutions of Central Ohio or a representative. These images or clips may be shared with staff, other physicians or healthcare professionals, and members of the public for educational or marketing purposes.

By consenting to photographs and/or video images I understand I will not be compensated from any party. I acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever.

Please choose of the following options regarding the authorized use of photographs and/or video images:
Please review and check each of the following:

Tell Us How We're Doing

Your feedback matters to us! If you’ve had a positive experience with Impact Health & Wellness, we’d greatly appreciate your Google review. Share your thoughts and help us continue making a positive impact on your health and well-being.