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.

     

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  • Consent

  • Thank 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:

    1. Authorization
      I, 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.

    2. Use of Photos and Videos
      I 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.)
    3. Privacy
      I 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.

    4. Duration of Use
      This consent is given with the understanding that photographs and videos may be used for an indefinite period unless I withdraw my consent in writing.

    5. Right to Revoke
      I 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.

    6. No Compensation
      I understand that I will not receive any compensation for the use of these photographs or videos.

    7. Release
      I 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.


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  • Clear Signature
    Important: You consent to sign this document electronically.