Patient Photo & Xrays Release Form

Please correct the errors described below.

I hereby authorize Dentistry at South Brunswick and/or any of their assignees to take photographs and/or videos of my face, jaws, and teeth. I understand that the photographs, slides, and/or videos will be used as a record of my care, and may be used for educational purposes in lectures, demonstrations, advertising (including website publication, social media, brochures), and professional publications (dental magazines and journals). I further understand that if the photographs and/or videos are used in any publication or as a part of a demonstration, my name (First Name Only) or other identifying information could be used unless stated differently below. I do not expect compensation, financial or otherwise, for the use of these photographs.

I do not mind if my first name, face, and teeth are used in any of the above stated situations.

General Dental Release

Please provide me with copies of all my dental records, x-rays, medication sheets, interpretations of tests, and progress notes pertaining to my treatment. I understand that my actual dental record, by law, belongs to my dentist. I understand that the information contained in the record belongs to me. I agree to accept copies of such records and to pay any fee(s) for duplication as required.

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.


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