Photo Release Form

EXTRAORDINARY SMILES, EXTRAORDINARY SERVICE

I grant Johnson Orthodontics the right to take photographs and/or video of me for the use and purpose of marketing photo and video stock. I authorize Johnson Orthodontics its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Johnson Orthodontics may use such photographs and/or video of me with or without my name and for any lawful purpose, including for example purposes as publicity, illustration, advertising, Web content and social media.

I have read and understand the above:
Date

MonthDayYear
Date
Patient Name*
Parent Name (if under 18)
Signature (patient or parent)

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Do you want us to tag you on Instagram? If yes, please indicate your user name:
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Should be Empty: