Photo Release | Huntersville Smiles Orthodontics & Kids Pediatrics – Forms

Photo and Video Release

I give permission for photographs and videos and identifying information of the persons listed below to be published on our website, Facebook page or any other marketing materials of Huntersville Smiles Orthodontics & Kids Dentistry (4605 Hylas Lane, Unit B Huntersville, NC 28078).

I understand that these photos/videos and identifying information can be viewed by anyone.

Is the patient over 18? *

I am over 18, and I give permission for my image to be published.

Yes
No

Patient Information

Patients’ Name *

First Middle Initial Last

Child’s Name *

First Middle Initial Last

Child’s Name

First Middle Initial Last

Acknowledgement Of Receipt Of Photo & Video Release By Patient *

By signing my name to this online form, I certify that I have read the information and that any questions concerning these policies have been discussed. My signature also certifies my understanding of and agreement with the policies or guidelines. A photocopy of this document is as valid as the original. You may receive a copy of this document upon request

Additional Information

Adult's Name *

First Middle Initial Last

Relationship to Patient *

Consent to be Tagged on Social Media

Check this box to give permission for social media tagging

Follow us @huntersvillesmiles on Instagram & smilehuntersville on Facebook

Add your Username/Handle if you would like to be tagged *

Acknowledgement Of Receipt Of Photo & Video Release By Parent/Guardian *

By signing my name to this online form, I certify that I have read the information and that any questions concerning these policies have been discussed. My signature also certifies my understanding of and agreement with the policies or guidelines. A photocopy of this document is as valid as the original. You may receive a copy of this document upon request