Photo Release and Authorization

Photo Release
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Goings Orthodontics Release and Authorization

From time to time, our practice features patients in clinical presentations, new patient consultations, and for advertising/marketing purposes. I herby give Goings Orthodontics and all persons and companies acting with their authority permission to use, re-use, publish and/or re-publish, any and all photographic portraits, pictures, and/or videographic pictures or recordings of me and/or my minor child(ren) listed below, or audio recordings of my voice or the voice(s) of my minor child(ren) listed below or in which I am (or they are) included, without restriction. I also consent to the use of printed matter in conjunction therewith.

I have read the above Release and Authorization, and I am familiar with the contents thereof.





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