Authorization:

I authorize the use and disclosure of my name, photography, video images, and testimonial for marketing purposes by the practice listed. I understand that information disclosed pursuant to this authorization may be subject to disclosure and may no longer be protected by HIPPA privacy Regulations.

Purpose:

The photographic/ video images, and or testimonial will be used for the following:

  • Dental Records, dental research, dental education including lectures seminars, demonstrations, publications such as journals or books, and marketing material including websites and printed materials, patient education, and social media.

Revocability:

I understand that I may revoke this authorization at any time but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive this authorization expires 99 years from date signed.

No Treatment Conditions:

I understand that the practice cannot condition treatment on whether or not I sign this recognition

Patient Information:

If Personal Representative or Patient is a Minor:

- OR -

Check here if you do not want your full face shot used for any of the above purposes.

SIGNATURE

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