Photography consent

Dr. Mark Safari DDS & Associates
Newtonbrook Dental (416) 223-2453
Forestwood Dental (905) 770-0099

Patient Name

Full Name

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.

Name of patient:

Full name

Patient signature:

Date