Photography/Video Consent Form

Patient Name*

First Name Middle Name Last Name

Photography/Video Consent Form

I hereby authorize Joseph A. Narde, D.D.S. and Willow Point Dental to take photographs of my face, jaws and teeth.

I understand that the photographs/videos will be used as a record of my treatment and care. They may also be used for demonstrations to other patients and dentist, as well as "before and after" pictures for our website and advertisements.

Emergency Contact

In Case of Emergency Please Call:

Name

Phone #

Area Code Phone Number

Relationship

Signature*

Your digital signature (full name) is as legally binding as a physical signature.

Date