Photo Consent Form

DENTAL PHOTOGRAPHY CONSENT FORM

 

I authorise: Dr James Bartalotta to take photographs, and or video of my face, jaws and teeth, before, during and after treatment. I consent to allow the photographs and or video to be used for the following:

  • Dental records.

  • Dental research.

  • Dental Education including lectures, seminars, demonstrations, professional publications such as journals or books.

  • Marketing material, including websites and printed materials, patient education.

 

I understand if any such media is used, my name and other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the usage of this media.

 

Thanks for submitting!