I consent to the use of my personal image and likeness, including but not limited to images or videos representing and depicting the treatment provided to me by Dr. Hill and Otter Orthodontics, and the effect thereof, for any lawful use Dr. Hill deems appropriate, including for treatment, advertising her services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Dr. Hill and Otter Orthodontics during the course of my treatment. Images which are medical records are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I hereby release the obligations of Dr. Hill and Otter Orthodontics with regard to the privacy of those images obtained by photographic or digital means. I understand that waiving my rights with regard to use of my image does not release Dr. Hill or Otter Orthodontics from any additional obligations under HIPAA. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials.

I understand any image or likeness of me may be altered prior to use if deemed appropriate by Dr. Hill and Otter Orthodontics. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used.

I understand that Dr. Hill and Otter Orthodontics will make all reasonable efforts to safeguard my privacy as required by applicable law, including the HIPAA. I understand, however, that Dr. Hill and Otter Orthodontics cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I understand and agree that Dr. Hill and Otter Orthodontics may use information regarding my health condition, including information regarding my diagnosis, course of treatment, my date of birth and/or age and my other relevant medical conditions, in describing the treatment rendered to me as depicted in any image or video of me.

I understand that Dr. Hill and Otter Orthodontics may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness.

I have read the foregoing in its entirety and understand its terms.