DENTAL PHOTOGRAPHY CONSENT FORM

Patient Consent
I, First Name Last Name Date. Give consent to BellaVista DentalCare to use dental images and/or video made of me or my child/dependent(s).


Full Face	Lower Face

I agree that the images may be:

(please initial below to show consent)

Electronically emailed to my treating dental specialist for treatment coordination and planning

Full FaceLower Face

Electronically emailed to my treating dental specialist for treatment coordination and planning - Full Face and Lower Face

YESNO

Used by health professionals for educationand training - Full Face

YESNO

Used by health professionals for educationand training - Lower Face

YESNO

Used in paper or electronic health publications - Full Face

YESNO

Used in paper or electronic health publications - Lower Face

YESNO

Used in marketing materials - Full Face

YESNO

Used in marketing materials - Lower Face

YESNO

Signature of Patient/Parent or Guardian

Date

DENTAL PHOTOGRAPHY CONSENT FORM

By signing below, I confirm that I understand this consent form.