www.bearleydental.net - Photography/ Social Media Consent & Release Form

Photography/ Social Media Consent & Release Form
Patient Name*

First NameLast Name
I {patientName} (Patient), authorize Bearly Dental PC to take photographs, and/or videos of my face, jaw, and teeth, before, during, and after treatment.
Dental records, research, and education including: lectures, seminars, demonstrations, professional publications such as journals and booksSocial media (Facebook, Instagram, Twitter, Google, Yelp, and Pinterest), marketing meterial including websites and printed meterials, and patient education FULL FACE/MOUTH.I refuse to share
I further understand that if photographs and or videos are used, my name or other identifying information will be kept CONFIDENTIAL (Other than if my full face, photos, and/or videos are used.
Patient’s Signature*

Clear
Patient’s Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: