Patient Photo Release Form

Stoppelbein & Hardison, DDS

Please correct the errors described below.

I, name stated above, authorize Stoppelbein & Hardison, DDS, PA to take photographs of my face, jaws, and teeth before, during, and after treatment. I consent to allow photographs to be used for the following:

  • Dental Records
  • Communication with other health care professionals
  • Marketing material (Website, Facebook, printed materials, etc.)

I understand that if the photographs are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs. If declining this consent, leave blank.

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

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