Authorization:
I authorize the use and disclosure of my name, photographic / video images, and / or testimonial for educational and / or marketing purposes by Aglow Dental Studio. I understand that information disclosed pursuant to this autorization may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations. I understand that I will not receive financial compensation.

Purpose:
My photograph / video images, and / or testimonial will be used for: Social Media and / or Advertising

Revocability:
I understand that I may revoke this authorization at any time, but such revocation must be in writing addresses to the practice. Revocation affects disclosure moving forward and is not retroactive. This authourization expires 5 years from date signed.