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
/
MM
/
DD
YYYY
2 digit month, 2 digit day, 4 digit year
Submit
Should be Empty: