Form: Photo and Video Release

Patient Information

Patient Photograph and Video Release

Consent and Release

I hereby acknowledge that I have been advised that photographs and/or videos ("Content") will be taken of me or parts of my head, face, neck and jaw before, during, and/or after certain dental procedures or treatment to document such procedures or treatment. This includes photos or videos taken prior to the date below. The Content will be taken on behalf or by one of the employees of Dr. Katie Allen, DMD and is the sole and exclusive property of Dr. Katie Allen, DMD and associates. I hereby give my consent to Dr. Katie Allen, DMD to use the Content for communication with other health care professionals, educational publications, educational lectures, patient and employee education, public education, marketing, promotions, advertising, posting on our office website, and posting on Dr. Katie Allen, DMD social media accounts. In giving consent, I understand and agree that any Content authorized under this agreement may include Protected Health Information under the Health Insurance Portability and Accountability Act ("HIPAA") related to my treatment, condition, procedure, or other service and may no longer be protected by HIPAA regulations.

I understand that:

  • I will not be identified by name at any time unless I give consent to do so.
  • Information shared with the public or posted on the Internet may be further shared by unrelated third parties for which Dr. Katie Allen, DMD has no control.
  • I may revoke this authorization in writing by contacting Dr. Katie Allen, DMD during normal business hours.
  • Should I revoke this authorization, such revocation shall only be applicable to Content used after the date of revocation.
  • No compensation, financial or otherwise, will be provided to me or my family.
  • This authorization shall remain in effect from the date signed until the earlier or revocation or 12/31/2050.

I hereby release and discharge the photographer, Dr. Katie Allen, DMD, it's employees, officers, directors, agents, representatives, subsidiaries and affiliates, and all successors and assigns, from any and all claims, damages, actions and demands in any way arising out of or in connection with the use of the Content as authorized by this Agreement.

Patient or Legal Guardian/Authorized Representative

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.