Consent To Dental Photography

Please enable JavaScript in your browser to complete this form.

Patient name

First

Last

Date of Birth

Address

Address Line 1

City

State / Province / Region

Postal Code

Email

CONSENT

I authorize Liverpool Dental Care to take photographs, and/or videos of my face, jaws and teeth before, during and after treatment. I understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.

Consent

I consent to allow the photographs to be used for the following: Dental Records, Dental Research, Dental Education including lectures, seminars, demonstrations, Professional Publications (journals or books), Marketing Material (websites or printed materials) and Patient Education.

Patient Signature

Please write full name

Date

Dr Amtul Saba
94 Moore St, Liverpool NSW 2170
Ph: 02 8124 8953
E: [email protected]
https://liverpooldentalcare.com.au/