FAMILY REGISTRATION

CONSENT FOR PHOTOGRAPHY

I understand that Surf's Up Pediatric Dentistry may take or receive photographs, video, audiotape. and other image and sound-based media of its office, including its employees, patients, and other visitors. Surf's Up Pediatric Dentistry may wish to use such photographs for educational, promotional, advertising, and other purposes. This permission for release, without compensation or prior notice, would allow Surf's Up Pediatric Dentistry to use photographs in its printed publications, during presentations, and otherwise. Therefore, I hereby freely and voluntarily consent to the use and publication of my name, participation, picture, or likeness by Surf's Up Pediatric Dentistry or its employees or agents for any and all purposes including, but not limited to:videotape, film, photograph, television, radio, digital, internet, theater, or exhibition, at any time from this date forward until I revoke this consent in writing. I further waive any claims against Surf's Up Pediatric Dentistry, its employees, or agents based upon or related to its use or publication of my likeness, voice. participation, or picture. I freely give this authorization without expectation of compensation.

 

 

 

AUTHORIZATION 

I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary services that my child may need. I assign the Doctor to all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover.