I {patientName}, hereby grant and authorize Buscemi Family Dentistry ( Dr. Vincent Buscemi) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration.
The authorization extends to all languages, media, formats, and markets now known or later discovered.
I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy.
Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.
I hereby hold harmless and release Buscemi Family Dentistry from all liability, petitions and causes of action which I, my heirs, representatives, executors, or other persons may make while acting on my behalf or on behalf of my estate.