Photo/Video Consent Form

We are seeking permission to use images, including still photographs or videos, of you and/or your child’s likeness, poses, acts and appearances as visual material that may be incorporated into publications, advertisements, audio-visual presentations and/or web pages produced in connection with the advertising, promotion, and marketing of Quarry Park Dental, its programs and services. Quarry Park Dental may crop, alter or modify images of you and/or your child, and combine such images with other images, text, recordings, and graphics in the production of such materials. Yes, I give Quarry Park Dental permission to take and use my photograph and/or video image for inclusion in public information and promotional materials produced by Quarry Park Dental.

I certify that I am the parent or guardian of the patient listed above and do hereby give my permission to the foregoing on behalf of this person.