• Authorization: I authorize the use and disclosure of my name, photo-graphic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.

    Purpose: The photographic/video images, and/or testimonial will be used for: Dental Records, dental research, patient education, Social Media and/or Advertising.

    Revocability: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.

    No Treatment Conditions: I understand that the practice cannot condition treatment on whether or not I sign this authorization.

    I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential.
    I do not expect compensation, financial or otherwise, for the use of these photographs.
  • Practice Name: Carmel Mountain Dentistry

  • Date Format: MM slash DD slash YYYY
  • If Personal Representative

  • Date Format: MM slash DD slash YYYY
  • If Patient is a Minor

  • Date Format: MM slash DD slash YYYY