Authorization for Release of Photograph, Video, or Written Testimonials

by signing this release, authorize Dr. Geivelis, his staff, and anyone else they authorize to use photographs, video images, or other likenesses of myself and my procedures, for the following purposes:

1. Use in Dentist or Patient education and training activities and materials (including print and on line or electronic instructional materials); and
2. Use in print or electronic form in publications, presentations, brochures, newsletters/bulletins, and websites for educational, public relations or promotional purposes.

I understand that the images and written testimonials described above may be included in, copied and distributed by means of various print or electronic media. I understand that my name will not be included with the images or testimonials.

This Authorization is given without promise of compensation. The photos, video images or other likenesses and the attached testimonials specified above become the property of Dr. Geivelis and I release to them any right, title, and/or interest of any kind that I may have in the information or images produced.

I have read this document and understand its contents.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

The authorization must be signed and dated and a copy provided to the individual completing the form.