INFORMED CONSENT

Please read the following information and sign.

PHOTOS AND IMAGES: Unless otherwise indicated, I hereby give my consent for the use of my photographs, slides, videotape, and/or computer images of face, jaw, and teeth that were taken for medical purposes, to be used by the office for social media, marketing, and/or educational purposes. I understand I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits. I understand that I may revoke this authorization in writing at any time by sending a letter to my dental care provider stating my revocation and the effective date, except to the extent that action has been taken in reliance on this authorization.