I, {name} give D. Scott Stucki, DDS and Common Sense Family Dentistry permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of D.Scott Stucki, DDS and Common Sense Family Dentistry activities. I agree that D. Scott Stucki, DDS and Common Sense Family Dentistry have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with D. Scott Stucki, DDS and Common Sense Family Dentistry missions. These uses include, but are not limited to, illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, social media and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release D. Scott Stucki, DDS and Common Sense Family Dentistry and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.
I have read and understood this consent and release.
I give my consent to D. Scott Stucki, DDS and Common Sense Family Dentistry to use my name and likeness to promote D. Scott Stucki, DDS and Common Sense Family Dentistry program, its fiscal agent, and/or their activities.