ashevillesmiles.com - Photo Consent Form

ASHEVILLE SMILES PHOTO CONSENT FORM
I, First Name Last Name , grant permission to Rebekkah A Merrell, DMD, MS PLLC /Asheville Smiles Cosmetic & Family Dentistry to photographs being taken of me. I understand that they may be used for education, documentation, and illustration of my treatment. I grant Asheville Smiles and its team the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me for the documentation of my dental care, education, publication, promotion, or advertising in any manner or in any medium.

I understand that there shall be no payment for this release.

I hereby release Rebekkah A Merrell, DMD, MS PLLC/Asheville Smiles Cosmetic & Family Dentistry and its legal representatives for all claims and liability relating to said videos or images.

I understand that I may revoke this authorization at any time by notifying the Releasee in writing. The revocation will not affect any actions taken before the receipt of this written notification.

We, the Releasor and Releasee, have understand and agree to the aforementioned terms and conditions.
I GIVE my permission to have photographs taken.

YESNO
I DO NOT give permission to have photographs taken other than for my own dental care documentation.

YESNO
If legal guardian of patient(s), please list the name(s) here:
Name(s):
Signature:

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Date:

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ASHEVILLE SMILES PHOTO CONSENT FORM