Photo Release Form

I hereby authorize Great Smiles Dental or any of their assignees to take photographs, slides, and videos of

Patient's Name

's teeth, jaws, and face. I understand that the photographs, slides, and videos will be used as a record of my care, and may 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, social media 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 other the use of these photographs. If I wish to revoke this consent, I may do so in writing.

Please write your INITIALS in ONE of the following options:

Initials

I do not mind if my photographs are used in any of the above stated situations.

Initials

I only agree to have my teeth shown without any identifying features.

Signature of Patient or Legal Guardian or Authorized Representative

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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