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.
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.
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