www.pateldornheckerdds.com - Digital Photo Waiver and Consent Form

DIGITAL PHOTO WAIVER AND CONSENT
Patient Name

First NameLast Name
Date

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I {patientName} the undersigned, do hereby authorize and consent to the use of certain digital photographs and/or radiographs of me taken by Patel & Dornhecker Dentistry. I hereby grant them permission to reproduce, publish, print, use, and distribute copies of such photographs/radiographs either in an official medical publication or in lectures for educational purposes or for advertising purposes. I further grant permission for my digital photos to be used on www.pateldornheckerdds.com (practice website) for educational purposes.
(No full face or identifying photos will be used without your expressed written consent)
PLEASE INITIAL ONLY (1) OF THE FOLLOWING:
I do consent to the use of digital photos (full face) for use in dental education and/or publications, including the website, www.pateldornheckerdds.com
I do consent to the use of digital photos (no full face) for use in dental education and/or publications, including the website, www.pateldornheckerdds.com
I do not consent to the use of digital photos and/or X-rays for use in dental education or publications. These records are strictly for use in my plan of care.
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First NameLast Name
Date*

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DIGITAL PHOTO WAIVER AND CONSENT