I, {patientName25} the undersigned, do hereby authorize and consent to the use of photographs/x-rays of me taken by Titus Dentistry. I grant them permission to reproduce, print, and publish photographs taken of me in a professional publication or in the form of prints, film, or slides in connection with articles and lectures dealing with the jaw or dental disorders. I specifically waive any claim for invasion of my personal privacy which might accrue to me on account of the use of such pictures without my express consent in each instance.
I do consent to the use of my photographs or images for marketing materials, including website and patient education, for Titus Dentistry only. I further understand that if the photographs and/or images are used, my name or similar identifying information will not be used. No full face or comparable photos will be used without your express written authorization.
I further acknowledge that my participation is voluntary and that I will not receive any compensation, financial or otherwise, with respect to the taking, use, or publication of these photographs for any dental office publications. I acknowledge and agree that publication of photographs confers no rights of ownership or royalties whatsoever.