Patient Photo & Xrays Release Form

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.

Please initial:

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

Exceptions:

I do not wish to have my First Name shown, or released.

I do not wish to have my face shown.

I only agree to have my teeth shown without any identifying features.

I do not wish to have my photos used at all.

X-rays Release Request Date

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.

Patient Name

Patient/Guardian Signature

Date

Date of Birth

SSN No.

Previous Doctor's Name

Doctor's Phone No.

RELEASE SEND X-RAYS TO:

DR. NAME:

ADDRESS

CITY

STATE

ZIPCODE

Office Use Only:

Date Received:

Date Copies Mailed:

Date Copies Emailed:

Staff Initial:

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