Photo/Testimonial Release Form

Patient Name:

D.O.B.

I hereby acknowledge that photographs of my face and teeth will be taken by an employee as a part of my visit and my dental records. I understand that I may be asked to give a testimonial about my experience here. I understand that any photos or testimonials I authorize for use may be featured on social media, websites, and other informational materials to inspire and educate both the public and patients. I hereby give my consent for use of the photographs and/ or testimonial I have given under one of the following circumstances:

All photos/testimonial to be used to educate the public and other patients about the amazing outcomes of all dental procedures performed.

Only close up photos to be used to educate the public and other patients about the amazing outcomes of all dental procedures performed.

I decline the use of any photos to be used to educate the public and other patients about the amazing outcomes of all dental procedures performed.

Type of testimonial consented:

Voice testimonial

Video testimonial

We want to celebrate the success of all of our patients’ smiles through photos and testimonials. Sharing your smile journey can inspire someone else to begin their smile journey too!

Patient Signature

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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