By initialing below, I __________________________________ (name of patient), do hereby authorize the
practice listed below to use and/or disclose the following health information about me on their website and
social media for marketing and educational purposes:
___ Photography, video, audio, and/or written testimonial(s) from me
___ Information about my specific treatment and/or dental condition
___ My first name
___ My age
___ My city, county, or state of residence
I understand any and all reproductions of materials including my image, voice, condition/treatment,
or personal testimony remains the property, solely and completely of the practice listed below, to be used
exclusively for the promotion of the practice listed below, including, but not limited to, on its website and
social media.
I understand that by signing below I am voiding any previous elections to “opt out” of releasing my health
information for the express purpose(s) outlined above.
I fully understand that I may refuse to sign this authorization and that my refusal to sign will not aect my
ability to obtain treatment or my eligibility for benefits.
Finally, I do understand that I may revoke this authorization any time, provided that I do so in writing.
I also understand that information released between the eective date of this authorization and the date
of the revocation may still be used in the public domain.
Patient Photo Release Form
Practice Name _____________________________________________________________________
Print Patient Name(s) _________________________________________ Date ____________________
Signature of Patient or Patient’s Representative ______________________________________________
Print Name of Personal Representative (if applicable) __________________________________________
Relationship to Patient __________________________________________________________________
Additional compliance rules vary from state to state. Consult legal counsel to ensure compliance with local laws and HIPAA regulations.
