Social Media
CONSENT FORM

Patients Name:

Date of Birth

Age:

Phone Number:

Address:

City:

Code:

Before you/your child’s photo can be displayed on our Social Media accounts, we must have your permission.

I understand that my photo and/or my child’s photo may be published on Forest Orthodontics & Pediatric Dentistry’s Website and Social Media Accounts, listed below:

Facebook:

facebook.com/ForestOrthoPedo

Instagram:

instagram.com/ForestOrthoPedo

Website:

forestorthopedo.com

To whom it may concern:

The undersigned does hereby give permission for my photo/ and or our (my) child, to use photos on Forest Orthodontics & Pediatric Dentistry’s Website and Social Media Accounts.

YES, you may use my photo/ my child’s photo on forestorthopedo.com, facebook.com/ForestOrthoPedo & Instagram.com/ForestOrthoPedo:

NO, you may not use my photo/ my child’s photo on forestorthopedo.com, facebook.com/ForestOrthoPedo & Instagram.com/ForestOrthoPedo

Signature/Parent Signature/Legal Guardian

Draw your signature in the box below with your mouse or cursor.

Date:

Social Media CONSENT FORM

Social Media
CONSENT FORM