CONSENT TO DENTAL PHOTOGRAPHY
I consent to the use of my dental photography, videos, and/or x-rays of the procedure to be shown for the advancement of dentistry, provided my identity is not revealed and kept confidential.
I understand that they may be used for:
*
Legal documentation
Social media
Dental research
Educational material, including lectures, seminars, demonstrations, and professional publications such as journals or books
Marketing material, including websites, printed materials, and patient education
I do not expect compensation, financial or otherwise, for the use of these photographs.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name (Please print)
*
First Name
Last Name
CYPRESS DENTAL
1845 West 4
th
Ave, Vancouver, BC, V6J1M4
Tel: 604-336-9360
www.cypressdental.ca
Submit
Should be Empty: