DENTAL PHOTOGRAPHY CONSENT FORM

Patient Consent
I, First Name Last Name Date. Give consent to BellaVista DentalCare to use dental images and/or video made of me or my child/dependent(s).


Full Face	Lower Face

I agree that the images may be:

(please initial below to show consent)

Electronically emailed to my treating dental specialist for treatment coordination and planning

Electronically emailed to my treating dental specialist for treatment coordination and planning - Full Face and Lower Face

Used by health professionals for educationand training - Full Face

Used by health professionals for educationand training - Lower Face

Used in paper or electronic health publications - Full Face

Used in paper or electronic health publications - Lower Face

Used in marketing materials - Full Face

Used in marketing materials - Lower Face

Signature of Patient/Parent or Guardian

Date

DENTAL PHOTOGRAPHY CONSENT FORM

By signing below, I confirm that I understand this consent form.