PHOTO/VIDEO RELEASE FORM

Your dental history, medical conditions, and specific concerns are unique to you. By having access to this information, your dentist can tailor their approach to your individual needs. This personalization ensures that your treatment is both effective and comfortable.

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I hereby authorize Dr. Shari Mathews or his team members to take photographs and/or videos of my face, jaws, mouth, and teeth in connection with my diagnosis and treatment. I agree that such information will become a part of my dental records. I understand that the photographs and/or videos will be used as a record of my care or as a method of communication with dental labs. These records may also be used for educational purposes in study club meetings, lectures, seminars, demonstrations, professional publications (journals, magazines) or for promotional purposes. I further understand that if the photographs and/or videos are used in any publication, demonstration or promotion, my name or other identifying information will be kept confidential. I do not expect compensation, or financial or otherwise, for the use of these photographs/videos.

PHOTO/VIDEO RELEASE FORM

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