We take a lot of photographs for record keeping purposes in our clinics. Each patient coming to our clinic will have photographs taken therefore it is important that you understand why we take photographs.
I, _____________________________________,
hereby authorize Dr. _______________________ or his assistants to take photographs, slides, and/or videos of my face, jaws, mouth, and teeth.
I understand that the photographs, slides, and/or videos will be used as a record of my care, and may be used for educational purposes in study club meetings, lectures, seminars, demonstrations, and professional publications (journals, magazines).
I further understand that if the photographs, slides, and/or videos are used in any publication or as a part of a demonstration, my name or other identifying information will be kept confidential.
I do not expect compensation, financial or otherwise, for the use of these photographs.
Signature __________________________________
Date ______________________________________
