I (Patient), authorize Dr. Mark Safari DDS,
to take photographs, and/or videos of my face, jaws and teeth, before, during and
after treatment. I consent to allow the photographs to be used for the following:
- Dental Records
- Dental Research
- Dental Education including lectures, seminars, demonstrations, professional
publications such as journals or books
- Marketing material such as social media, our office websites, Instagram,
Twitter, Facebook etc. as well as printed materials, and patient education.
I further understand that if the photographs and/or videos are used, my name or
other identifying information will be kept confidential. I do not expect
compensation, financial or otherwise, for the use of these photographs.