Periodontal Treatment Photo and Video Release Authorization

Patient Information

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

Authorization

I, _________________________________, hereby authorize Dr. _________________________ and their periodontal practice staff to take, produce, and use clinical photographs, videos, digital images, and/or audio recordings of my oral/periodontal condition, treatment, and procedures for the following purposes:

• Clinical documentation and treatment planning
• Dental education and training
• Scientific publications and presentations
• Marketing and promotional materials
• Patient education resources

Terms and Conditions

1. I understand that these images/recordings may include close-up views of my mouth, teeth, gums, and face.

2. I acknowledge that my identity may be revealed by the photographs, videos, or case descriptions, though reasonable efforts will be made to protect my privacy when possible.

3. I understand that I will not receive, and hereby waive any right to, royalties or other compensation arising from the use of these images/recordings.

4. I retain the right to revoke this authorization in writing at any time, though this will not affect any materials already published or in use.

Specific Permissions (Initial all that apply)

_____ Clinical documentation and internal use _____ Educational presentations and professional training _____ Scientific journals and publications _____ Practice website and social media _____ Marketing materials and patient education

Signatures

Patient Signature: _________________________ Date: ____________

Witness Signature: _________________________ Date: ____________

Practitioner Signature: _____________________ Date: ____________

Revocation

This authorization will remain valid unless revoked in writing. To revoke this authorization, please contact our office in writing at:

[Practice Name and Address]

Form ID: PERIO-PHT-001 Version: 2.0 Last Updated: [Date]