INFORMED CONSENTPlease read the following information and sign.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PHOTOS AND IMAGES: Unless otherwise indicated, I hereby give my consent for the use of my photographs, slides, videotape, and/or computer images of face, jaw, and teeth that were taken for medical purposes, to be used by the office for social media, marketing, and/or educational purposes. I understand I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits. I understand that I may revoke this authorization in writing at any time by sending a letter to my dental care provider stating my revocation and the effective date, except to the extent that action has been taken in reliance on this authorization.I DO consent to the use of my photographs, slides, videotape and computer images.I DO NOT consent to the use of my photographs, slides, videotape and computer images.LayoutName *Custom Captcha * = Date Submit