PHOTOGRAPHIC MEDIA AND/OR SOCIAL MEDIA CONSENT

• I hereby consent to the collection and use of my personal images by photography or video recording.
• I further acknowledge that Jacobson & Tsou Orthodontics may use my image in media to promote the practice in the future.
• I understand that no personal information, such as names, will be used in any publications unless express consent is given.
• I also understand that my consent can be withdrawn at any time in writing to Jacobson & Tsou Orthodontics.
• Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Jacobson & Tsou Orthodontics and its affiliates and agents, to use my image, video and photographic likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet and Social Media sites).