www.lcdcare.ca - Authorization For the Taking and Publication of Photographs/Videos Form

Authorization For the Taking and Publication of Photographs Form
Photographs are an important part of the examination process and are essential when developing a diagnosis and appropriate treatment options. When the doctor evaluates your records after the examination, it is important to have photographic documentation and X-rays to make a complete and proper diagnosis. To a lesser extent, photographs are also essential when communicating with other healthcare professionals.

In connection with the dental services which I am receiving from Lake Chaparral Dental Care, I authorize that photography may be taken of me, such as my face, jaws, and teeth, under the following conditions:
1. The photographs may be taken only with the consent of the attending doctor.
2. The photographs shall be used for dental/medical records.
3. Photographs shall be taken to diagnose dental conditions, plan treatment, documentation and education about your dental condition. Within your electronic health record, dental photographs illustrate the following - how the structures and landmarks of the face frame a person’s smile; the presence or absence of oral/dental disease; how a person’s teeth come together to form their bite; the anatomy of a person’s mouth, jaws, and teeth; before and after treatment comparisons; the progression of the disease and the return to health from a state of disease.
Please initial your permission to allow us to use your photos for our marketing or social media purposes, such as on our Website, Facebook, Instagram, YouTube, Twitter, Pinterest, and Blog. The images that we will use are the before and after shots and testimonials. We assure you that the photographs would only display the individual's smile/lips, before and after smile photos or teeth photos and not include other facial recognition characteristics.
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I fully understand and accept the terms of this authorization.
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Authorization For the Taking and Publication of Photographs Form