Sample Photography Release Form
Sample Photography Release
I ___________________________________the undersigned, do hereby authorize and consent to the use of
photographs/x-rays of me taken by [insert dental office name]. I grant them permission to reproduce, print and publish
photographs taken of me in a professional publication or in the form of prints, film or slides in connection with articles
and lectures dealing with the jaw or dental disorders. I specifically waive any claim for invasion of my personal privacy
which might accrue to me on account of the use of such pictures without my express consent in each instance.
I do consent to the use of my photographs or images for marketing materials including website and patient education
for _____(name of practice)______________________ only. I further understand that if the photographs and/or
images are used, my name or similar identifying information will not be used.
No full face or comparable photos will be used without your express written authorization.
I further acknowledge that my participation is voluntary and that I will not receive any compensation, financial or
otherwise, with respect to the taking, use or publication of these photographs for any dental office publications. I
acknowledge and agree that publication of photographs confers no rights of ownership or royalties whatsoever.
Patient’s Name: _____________________________________________________
Patient or Guardian Signature: _________________________________________
Dentist Signature: _________________________________Date: ______________
Street Address: ______________________________________________________
City: __________________________ State: ________ Zip: ___________________
[Dental Office Name]
[Office address]
[Office city, state, zip code]
© ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use,
duplication or distribution by any other party requires the prior written approval of the American Dental Association.
This material is educational only, does not constitute legal advice, and may not satisfy applicable state law.
Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional for
legal or professional advice.
