I hereby consent to having {patientName}'s picture appear in electronic media or print publications that Dr. Schatz Orthodontics might choose to release. I
understand that his/her picture may be on display in accordance with any of the above mentioned activities. I further acknowledge that my child’s name may or may not be used in connection with his/her picture.

I hereby agree on behalf of the above named student and with agreements of his/her parent or legal guardian to waive any claims against Dr. Eric Schatz and his staff which may arise from the use of any pictures used in accordance with Schatz Orthodontics advertising.

If at any time, I want my child’s photograph to be removed from Dr. Schatz Orthodontics web site or other electronic media, I acknowledge that it is my responsibility to inform either the doctor or his staff in writing.