Educational & Marketing Portfolio Consent

An Invitation to be part of our Educational & Marketing Portfolio

Professional patient consent form and model release for

Photographic, video & written testimonial reproduction

Name of patient or next of kin
In cases where the patient has died or is incapable of giving consent, consent may be given by the next of kin. If the patient is under the age of 16, consent should be given by a parent or guardian.
First Last
If next of kin, state relationship to patient
Email
Address
Street Address Address Line 2 City ZIP / Postal Code
An Invitation to be part of our Educational & Marketing Portfolio
Please tick below to confirm whether or not you would like us to; include identifiable / non-identifiable video(s) and photograph(s) of me / my son/daughter and written testimonial(s) in patient information and education resources including printed and online leaflets, brochures, CDs, websites, advertising, video hosting sites including YouTube, social media sites including Facebook, Instagram, Internet search engines including Google, and other Internet Publications, for perpetual and commercial use.
Video(s)*
- Identifiable
- Non-identifiable
photograph(s)*
- Identifiable
- Non-identifiable
Treating Dentist Name
Consent
I agree to the privacy policy.
In cases where the patient has died or is incapable of giving consent, consent may be given by the next of kin. If the patient is under the age of 16, consent should be given by a parent or guardian.
Consent*
I declare, in consequence of granting this permission, that I have no claim on ground of breach of confidence or on any ground in any legal system against (name of dentist above) in respect of the publication of the video(s), photograph(s) and written testimonial(s).*
Signature*
Photography Consent Signature
Date
DD slash MM slash YYYY