Form
Name
First Name
Last Name
consent
I give permission for to Dr Elena Horri to use videos/photographs in connection with my treatment in their house portfolio, social media sites, professional publications and other marketing material or clinical Consent to share details of your treatment, Consent to share smile photos (teeth/lips) Consent to share treated area only Consent to share video footage I fully consent and understand this form and agreed to it
Consent to share for full face photos or video
yes
no
date of Birth
Signature
Submit
Should be Empty: