Dental Photography Consent & Authorization Form

1. Clinical Documentation Consent

I understand that photographs, digital images, and/or video may be taken of my teeth, smile, face, and/or oral structures as part of my dental examination, diagnosis, treatment planning, progress documentation, and dental record.

I authorize the practice named above and its clinical team to:

• Capture clinical photographs and related images for treatment and documentation;
• Store those images as part of my dental record;
• Use those images for treatment, payment, and healthcare operations consistent with applicable privacy laws and the practice’s Notice of Privacy Practices.

2. Marketing / Educational Use (Optional)

Separate from clinical documentation, I may choose to authorize additional uses of my images. Marketing and educational uses are optional. Declining this section does not affect my clinical care.

If I check any box below, I authorize the practice to use my photographs (including before-and-after images) for the selected purposes. I understand that such uses may be public or semi-public and that I may be identifiable.

3. Revocation Rights

I understand that I may refuse clinical photography when it is not required for my care, and that I may revoke any marketing or educational authorization at any time by providing written notice to the practice. Revocation does not affect uses already made in reliance on this authorization before the practice received my written revocation. After revocation, the practice will stop new marketing/educational uses of my images and will make reasonable efforts to remove images from public channels under its control when feasible.

4. Acknowledgment & Signatures

I have read this form (or had it read to me), understand it, and have had the opportunity to ask questions. I am signing voluntarily. If signing for a minor or legally incapacitated adult, I represent that I am authorized to do so.