Social Media Use and Disclosure Consent

Consent to Use and Disclose Treatment Information and Photographs for Social Media Purposes

We value our patients’ right to privacy and confidentiality, and we take our responsibilities under HIPAA and the Texas Medical Records Privacy Act very seriously. The practice exercises great care in the use of patient images and patient identities to promote the practice via social media. Specifically, we pledge not to disclose or discuss:

  • Your past, present, or future physical or dental health or condition;
  • Discriminatory or potentially negative information of a personal or professional nature, and
  • Past, present, or future payment for your health care.

By signing below, you grant our office permission to use an approved photograph of yourself along with a brief approved description for promotional purposes via social media.

You understand that this authorization may be revoked at any time merely by notifying our office that you wish us to discontinue using your photograph(s) and brief description(s) for promotional purposes.

Finally, your willingness to participate in social media promotion will have no effect on the treatment you receive from our office and staff. If you decline to allow us to use your photograph(s) and description(s), your treatment or experience as a patient of our practice will not be affected.

Patient First Name:
Patient Last Name: