Confidential Patient Information

First Name:

Middle Initial:

Last Name:

Mitchell Bartlett & Bell Orthodontics would like your permission to take photographs and/or videos of you before, during and after treatment.

These photographs and/or videos will be used on various social media sites including, but not limited to, our website, FaceBook, Instagram, in-office digital displays, and digital/printed marketing materials.

I understand my consent is completely voluntary and that I will receive no compensation, financial or otherwise, now or in the future, for the use of my images.

Patient Signature (18 & above):

Parent/Guardian Signature (if patient is a minor):

Date: