Photo and Video Consent Agreement Please complete this Consent for Photo and Video form below. If you have any questions call us on (615) 915-6090. HiddenVersion historyv1.0 : First version (add), 2024-09-27Patient name:(* required) First Last Patient date of birth:(* required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 ConsentThank you for trusting our Office with your dental care. We kindly request your consent to use photos and/or videos taken during your visit for educational, promotional, and informational purposes. Please carefully read and sign the agreement below. Consent Terms: AuthorizationI, the undersigned, hereby grant Michael D. Vaughan, DDS and its affiliates, representatives, and employees the right to photograph or record videos of me or my child/ward during treatment or other dental procedures. Use of Photos and VideosI consent to the use of these photographs and videos for any lawful purpose, including but not limited to: Educational purposes (seminars, training, conferences, etc.) Promotional materials (brochures, website, social media, etc.) Informational materials (newsletters, blog posts, etc.) PrivacyI understand that identifiable personal health information, such as my name or my child’s/ward’s name, may be disclosed without a need of an additional written consent.Michael D. Vaughan, DDS will not sell these materials to third parties. Duration of UseThis consent is given with the understanding that photographs and videos may be used for an indefinite period unless I withdraw my consent in writing. Right to RevokeI understand that I may revoke this consent at any time by providing written notice to Michael D. Vaughan, DDS, but that such revocation will not affect any prior use of the photos or videos. No CompensationI understand that I will not receive any compensation for the use of these photographs or videos. ReleaseI hereby release and discharge Michael D. Vaughan, DDS, its agents, and employees from any and all claims, demands, or liabilities arising out of or in connection with the use of the photographs or videos. SubmitName of Legal Guardian or Authorized Representative:(* required) If not applicable use 'self'Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Consent?(* required) Yes No E-mail address:(* required) By signing below, I agree that I have read, understand, and agree to the terms of this agreement.(* required)Important: You consent to sign this document electronically.
