# YTMSEN · Release forms (DRAFT for review by US counsel)

Prepared by RYA.AE, 26 Oct 2026. Not legal advice. Have a US attorney review before use. Hospitals may require their own forms instead.

---

## 1. Participant appearance release (physician)

Participant: ______________________ (name, credentials)  Practice / institution: ______________________
Producer: R.Y.A Media Lab FZE (RYA.AE), United Arab Emirates, producing the YTMSEN patient-education channel.
Recording date and place: ______________________

1. Consent. I agree to be filmed and recorded for an educational video about multiple sclerosis, and to the use of my name, likeness, voice, credentials and professional affiliation in the episode, short clips cut from it, thumbnails, descriptions and promotion of the channel and of RYA.AE's work.
2. Review. Before publication I may review the final cut for medical accuracy. The producer will make reasonable corrections (up to two rounds).
3. No payment, no endorsement. I take part without payment. The video does not endorse any product. I will tell the producer about financial relationships relevant to the topic (for example, consulting for a drug maker) so they can be disclosed in the description.
4. Patient privacy. I will not disclose protected health information. Case examples will be de-identified.
5. License to my practice. My practice and I receive a non-exclusive, perpetual, royalty-free license to use the final episode and clips on our own channels, website, social media and in the clinic.
6. Educational content. The video is general education, not medical advice, and carries a disclaimer.
7. Withdrawal. Before publication I may withdraw by written notice. After publication the producer will consider reasonable requests to unlist.
8. Term and territory. Worldwide, in all media, without time limit, subject to sections 2, 5 and 7.

Participant signature: __________________  Date: ________
For the producer (Roman Sergeev, Manager, R.Y.A Media Lab FZE): __________________  Date: ________

---

## 2. Location release (clinic or office)

Property: ______________________ (name, address)  Authorized representative: ______________________
Date(s) and time window: ______________________  Areas: ______________________ (for example: consultation room, corridor, exterior sign)

1. The property allows the producer (one or two people, battery lights, two cameras) to film in the areas above and to show the property's name and signage: yes / no.
2. No patients, patient records or screens with patient data will be in frame. Staff appear only with their consent.
3. The producer leaves the areas as found and is responsible for damage caused by the crew.
4. A certificate of insurance will be provided on request, naming the property as additional insured.

Property representative signature: __________________  Date: ________
For the producer: __________________  Date: ________

---

## 3. If a patient appears

Use the clinic's own HIPAA authorization for photography and video, plus an appearance release adapted from section 1 (no license-back clause, explicit right to withdraw before publication). Film only after both are signed.

---

## 4. Description disclosure line (every episode)

Dr. [Name] took part without payment and reviewed this video for accuracy. Produced by RYA.AE for YTMSEN, an independent MS education channel funded by a private sponsor. No pharmaceutical or device-company funding. Educational content, not medical advice.

(Pending check against the FTC Endorsement Guides and state rules; see research notes.)