Photographic Authorization & Release

I authorize KEWASKUM FAMILY DENTISTRY, and/or their representative(s), to take photographs or intra oral photographs in connection with dental procedure(s) for patient education and or treatment planning purposes to be performed by KEWASKUM FAMILY DENTISTRY. I understand that such photographs are needed for my evaluation and dental treatment and may be taken before, during and after my procedure(s). (not for social media or promotion)

I do authorize the use of these images in office photo albums, websites, social media, newspapers, magazines, television or radio, billboard or any type of advertising without compensation to me now or in the future.

I release and discharge Dr. Sara Klasinski and/or KEWASKUM FAMILY DENTISTRY from all liability, including liability for negligence, that in any way arises from all rights that I may have in the photographs or video of me that I have authorized to be used and disclosed in this Authorization; and any claim that I may have relating to such use and disclosure of those photographs or videos of me, including any claim for payment in connection with any distribution of publication of them in any medium.

This Authorization is made as a voluntary contribution in the interest of public education and I certify that I have read this Authorization and Release carefully and fully understand its terms.

Patient Signature

Patient Name

Today's Date

Parent, Legal Guardian or Representative

Relationship to Patient

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Payment is due in full at the time of treatment unless prior arrangements have been approved.

Your information will be encrypted.

Photographic Authorization & Release

Patient Signature

Payment is due in full at the time of treatment unless prior arrangements have been approved.

Kewaskum Family Dentistry