Endodontic Treatment Photo and Video Release Authorization

Patient Information

Name: _________________________ Date of Birth: _________________ Chart Number: ___________________ Date: _________________________

Authorization

I, _________________________, hereby authorize Dr. _________________________ and associates to take clinical photographs, videos, and/or digital images of my oral/dental condition, treatment procedures, and results. I understand these may include close-up images of my teeth, gums, jaw, and face as relevant to my endodontic care.

Permitted Uses

I authorize the use of these images/videos for the following purposes (initial all that apply):

___ Dental Records and Treatment Planning ___ Educational Purposes (teaching, presentations) ___ Professional Publications ___ Marketing Materials ___ Practice Website and Social Media ___ Insurance Documentation

Understanding and Agreement

• I understand that these images/videos will be stored securely and handled confidentially
• I understand that I will not receive compensation for any use of these images/videos
• I understand that I may revoke this authorization in writing at any time
• I understand that revocation will not affect any actions taken before receiving my revocation

Restrictions (if any)

Signatures

Patient Signature: _________________________ Date: ________________

Witness Signature: _________________________ Date: ________________

Practitioner Signature: _____________________ Date: ________________

Revocation

I hereby revoke this authorization (complete only to revoke):

Signature: _______________________________ Date: ________________