RELEASE AUTHORIZING USE OF PHOTOS
BY ONSHORE ORTHODONTICS

Patient First Name:
Patient Middle Initial:
Patient Last Name:
I, (patient name)

to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Dr. David Dubiner or Dr. Hayley Woolfson for any lawful use they deem appropriate, including for advertising services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Dr. David Dubiner or Dr. Hayley Woolfson during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials.

I understand any image or likeness of me may be altered prior to use if deemed appropriate by Dr. David Dubiner or Dr. Hayley Woolfson. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used. As a general policy, we will make every effort to contact you before your images are used, but this cannot be guaranteed.

I understand that Dr. David Dubiner and Dr. Hayley Woolfson will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that Dr. David Dubiner and/or Dr. Hayley Woolfson cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I understand and agree that Dr. David Dubiner or Dr. Hayley Woolfson may use information regarding my health condition, including information regarding my diagnosis, course of treatment, my date of birth and/or age and my other relevant medical conditions, in describing the treatment rendered to me as depicted in any image of me.

I understand that Dr. David Dubiner or Dr. Hayley Woolfson may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness.

I have read the foregoing in its entirety and understand its terms.
Patient Name:
Patient/Parent/Guardian Digital Signature:
If patient is a minor, parent's name/guardian's name and relationship to the patient:
Date: