Patient Photo Release Form

I,   , hereby authorize Just Smilez Dental Or any of their assignees to take photographs, slides, and videos of my teeth, jaws, and face. I understand that the photographs, slides, and videos will be used as a record of my care, and may be used for communication with other health care professionals, educational publications (dental journals), and educational lectures. The content may also be used for advertising purposes (including website publication, Facebook posts, etc.).

I further understand that if the photographs, slides, and videos are used in any publication or as a part of a demonstration, my identifying information (first name only) could be used unless stated differently below. I do not expect compensation, financial or otherwise, for the use of these photographs. If I wish to revoke this consent, I may do so in writing.

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Signature Certificate
Document name: Patient Photo Release Form
lock iconUnique Document ID: 5a2e632622a4ed9130ecd7b7e7561c6dec2ffd65
Timestamp Audit
Feb 3, 2022 3:34 pm CSTPatient Photo Release Form Uploaded by Dr. Divya Sankepally - IP