Orthodontic Treatment Photo and Video Release Authorization

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: __________________ Date: _____________________

Authorization

I, ______________________, hereby authorize Dr. ______________________ and their orthodontic practice staff to take and use the following media of me/my dependent (check all that apply):

• Clinical photographs (intraoral and extraoral)
• X-rays and radiographic images
• Video recordings
• 3D scans and digital models

Permitted Uses

I grant permission for the above media to be used for the following purposes:

1. Clinical Documentation

   • Treatment planning and monitoring
   • Clinical record keeping
   • Insurance documentation

2. Professional Education

   • Staff training
   • Professional conferences
   • Continuing education courses

3. Patient Education

   • Demonstration of treatment procedures
   • Before/after treatment comparisons

4. Marketing (optional)

   • Practice website
   • Social media
   • Print materials

Terms and Conditions

1. I understand that these images/recordings will be used in a professional manner.
2. I understand that no identifying information will be disclosed without explicit consent.
3. This authorization remains valid until revoked in writing.
4. I may revoke this authorization at any time by written notice.

Signatures

Patient/Guardian Signature: _________________ Date: __________

Witness Signature: _________________________ Date: __________

Practice Representative: ____________________ Date: __________