Photo and Video Release Authorization Form

Patient Information

Name: _________________________ Date: _____________ Date of Birth: __________________ Chart #: ___________

Authorization

I, ______________________, hereby authorize [PRACTICE NAME] and its dental professionals to take clinical photographs, digital images, and/or videos of my face, jaws, mouth, and teeth.

Purpose and Usage

I understand that these images/videos may be used for the following purposes:

• Documentation of my dental condition
• Treatment planning and monitoring
• Educational purposes for other patients
• Professional clinical documentation
• Dental education and training
• Scientific publications
• Marketing materials (if specifically authorized below)

Specific Authorizations

Please initial next to your choices:

___ I authorize the use of my images/videos for internal clinical documentation only ___ I authorize the use of my images/videos for patient education ___ I authorize the use of my images/videos for professional education ___ I authorize the use of my images/videos for marketing purposes

Understanding and Rights

1. I understand that I will not receive payment or compensation for the use of these images/videos
2. I understand that I may revoke this authorization in writing at any time
3. I understand that all reasonable steps will be taken to protect my privacy
4. I understand that my treatment is not conditional upon signing this authorization

Signatures

Patient Signature: _________________________ Date: _____________

Witness Signature: _________________________ Date: _____________

For minors: Parent/Guardian: __________________________ Date: _____________

Practice Information

[Practice Name] [Address] [Phone Number] [Email]