By consenting to the use of these photographs as described above. I do not expect compensation, financial or otherwise, from Kind Orthodontics
I hereby release and discharge Kind Orthodontics from any and all claims and demands arising out of or in connection with the use of my name, photograph, or other information provided by me including any and all claims for libel and invasion of privacy.
I understand the receiving party may not further disclose this health information without first obtaining a new written authorization from me. I understand this authorization may be cancelled or modified at any time upon provision of a written notice to this dental practice. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibilty for benefits. I understand I may have a copy of this authorization.