Photo & Video Consent Form

Photo/Video Consent Form
Today's Date*
DD slash MM slash YYYY
Are you over the age of 18?*
We are seeking permission to use images, including still photographs or videos, of you and/or your child’s likeness, poses, acts and appearances as visual material that may be incorporated into publications, advertisements, audio-visual presentations and/or web pages produced in connection with the advertising, promotion and marketing of Parkway Smiles Dental, its programs and services. Parkway Smiles Dental may crop, alter or modify images of you and/or your child, and combine such images with other images, text, recordings, and graphics in the production of such materials. Yes, I give Parkway Smiles Dental permission to take and use my photograph and/or video image for inclusion in public information and promotional materials produced by Parkway Smiles Dental.
Name*
First Name Last Name
Signature*
I certify that I am the parent or guardian of the patient listed above and do hereby give my permission to the foregoing on behalf of this person.
Parent/Guardian Name*
First Name Last Name
Parent/Guardian Signature*

Photo/Video Consent Form