Photo Release and Authorization
GOINGS ORTHODONTICS RELEASE AND AUTHORIZATION
From time to time, our practice features patients in clinical presentations, new patient consultations, and for advertising/marketing purposes. I hereby give Goings Orthodontics and all persons and companies acting with their authority permission to use, re-use, publish and/or re-publish, any and all photographic portraits, pictures, and/or videographic pictures or recordings of me and/or my minor child(ren) listed below, or audio recordings of my voice or the voice(s) of my minor child(ren) listed below or in which I am (or they are) included, without restriction. I also consent to the use of printed matter in conjunction therewith.
I HAVE READ THE ABOVE RELEASE AND AUTHORIZATION, AND I AM FAMILIAR WITH THE CONTENTS THEREOF
Name(s) of minor child(ren):