PATIENT PHOTOGRAPH AND TESTIMONIAL AUTHORIZATION FORM

PATIENT PHOTOGRAPH AND TESTIMONIAL AUTHORIZATION FORM
Patient Name*

First NameLast Name
I herby give my consent for Showtime Orthodontics, PLLC to takephotographs, slides and/or videotape of my face, jaw, and teeth. I understandthat some of these images may be seen and used by other dental professionals,and these images will become part of the patient record.

If I have provided a written testimonial about my experience with ShowtimeOrthodontic Arts PLLC, I understand that my testimonial may be used in variousmedia including, but not limited to practice website, brochures, and printadvertising
Please circle “do” or “do not” for each statement, and initial.
consent to feature these images in professional articles andpresentations.*

I doI do not
consent to feature these images within the dental practice to beseen only by individuals who walk into the practice.*

I doI do not
consent to feature these images to promote the dental practicethrough various media, including but not limited to print advertising, brochures,and the practice website.*

I doI do not
By consenting to the use of these photographs and testimonial as described above, I do not expect compensation, financial or otherwise, from and Showtime Orthodontics, PLLC. I hereby release and Showtime Orthodontic, PLLC from any and all claims and demands arising out of or in connection with the use of my name, photograph, personal testimonial, or other information provided by me, including any and all claims for libel and invasion of privacy.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits.
Print Patient’s or Legal Guardian’s /Representative’s Name *

First NameLast Name
Patient’s or Legal Guardian’s /Representative’s Signature *

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PATIENT PHOTOGRAPH AND TESTIMONIAL AUTHORIZATION FORM

Please circle “do” or “do not” for each statement, and initial.