I authorize the use and disclosure of my name , photographic /video images , and/or testimonial for educational and/or markketing purposes by Aglow Dental Studio. I understand that information disclosed pursuant to this autorization may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations. I understand that I will not receive financial compensation.
My photograph/video images, and /or testimonial will be used for: Social Media and/or Advertising
I understand that I may revoke this authorization at any time, but such revocation must be in writing addresses to the practice . Revocation affects disclosure moving forward and is not retroactive . This authourization expires 5 years from date signed.