I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by H&A Orthodontics 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 H&A Orthodontics. I understand and agree that I have no right to be consulted about or approve such alterations before my image is used.

I understand that H&A Orthodontics will make all responsible 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 H&A Orthodontics cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I understand and agree that H&A Orthodontics 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 H&A Orthodontics may not and has not conditioned the rendition of treatment to me upon my authorization of use of my image and/or likeness.

I have read the foregoing in its entirety and understand its terms.