First Name *

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Email *

Address *

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I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Emergency Contact

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ELECTRONIC COMMUNICATIONS

I consent to receiving HIPAA-compliant electronic communications, such as email and text messages regarding treatment, payment, etc. I understand there is no obligation to receive these electronic communications.

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Date Signed *

CONSENT FOR DENTAL PHOTOGRAPHY

Please Check if You Authorize

I authorize Dr. Zev Schulhof, to take photographs, and/or videos of my face, jaws, and teeth, before, during and after treatment.

Dental Records, and Dental Research.
Dental education including lectures, seminars, demonstrations, professional publications such as journals or books.
Marketing material, including websites (facebook or instagram) and printed materials, patient education including TV.
Interstate BillBoard.

I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.

PLEASE CHECK ONE OF THE FOLLOWING *

I allow BOTH full face and mouth photos to be used for any of the purposes above.

I allow ONLY mouth photos to be used for any of the purposes above.

I don’t allow ANY of my photos to be used for any of the purposes above.

Patient Name *

Signature of Patient *

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