Patient Photo Release Form
Synergy Dental Solutions · Dr. Angie Tenholder, DMD, FAACP, DABCDSM, FAGD · 1000 Eleven South, Suite 3F, Columbia, IL 62236 · Phone (618) 281-9729 · Fax (618) 281-9734 · WeCare@WeAreSynergy.com
This form seeks consent for photographs to be taken by the Medical Institution through a doctor or a representative.
By signing this form, the patient affirms understanding that the images may be used for different purposes indicated hereunder.
By consenting to the release of images, you agree that you will not receive any form of compensation in cash or in kind.
You likewise understand that your name will not be included in the images. Nonetheless, it is still possible that someone may still recognize you.
Your refusal to consent to the release of your photographs will not, in any way, affect the medical care you will receive.
You may rescind your authorization to the release of the photographs by writing us a request.
I authorize the use of photographs for the following:
Educational purposes such as medical procedure demonstration
Social media and online publishing ads
Print marketing advertisements, video and television media advertisements
Sharing for provider education
I recognize that Dr. Tenholder is an educator on the techniques that many of our NeuralFORM patients are receiving. Dr. Tenholder utilizes patient case histories and images of teeth only to help other providers learn how to help children like yours. We would truly appreciate your consent to share images of your children's mouth, teeth and radiographic images as well as case history using a case number assigned to your child.
Consent to share for provider education
*
Yes, I give my consent
No, I do not give my consent
This consent is optional. Saying no will not affect your care in any way. It stays in effect until you withdraw it in writing.
Name of patient
*
First Name
Last Name
Is the patient under 18?
*
Yes
No
Signature of patient
*
Signature of parent/guardian
*
Parent/guardian name
*
First Name
Last Name
Date signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upon submitting this form, you affirm that all your responsibilities and rights have been explained to you.
Submit
Submit
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