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Consent to Dental PhotographyI, ______________________________ (Patient name), hereby authorize Comfortable Dentistry 4U to take photographs and/or videos of my face, jaws and teeth before, during andafter treatment.I consent to allow the photographs to be used for the following___ Dental Records, dental research, and dental education including study clubs,lectures, demonstrations, professional publicationsI further understand that if the photographs and/or videos are used, my name or otheridentifying information will be kept confidential.I do not expect compensation, financial or otherwise, for the use of these photographs.Signature: _______________________________________________ Date: ____________Parent/Guardian (for minors): ________________________________________________Witness: ________________________________________________ Date: ____________ ................
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