CONSENT TO DENTAL PHOTOGRAPHY

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Patient name

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Last

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CONSENT

I authorize Beautiful Smile Dental Surgery to take photographs, and/or videos of my face, jaws and teeth before, during and after treatment. I understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.

Consent

I consent to allow the photographs to be used for the following: Dental Records, Dental Research, Dental Education including lectures, seminars, demonstrations, Professional Publications (journals or books), Marketing Material (websites or printed materials) and Patient Education.

Patient Signature

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Date

Dr Amtul Saba
17/254 Pitt St, Merrylands NSW 2160
Ph: 0296378077
E: [email protected]
https://beautifulsmiledentalsurgery.com.au/