Photo/ Video Consent Form

Restorative Health

Photo & Video Consent Form

Patient Name

Date of Birth:

Date:

I CONSENT to medical photography/videography for treatment documentation.

I CONSENT to the use of my photos/videos for advertising and promotional purposes. I DO NOT CONSENT to the use of my photos/videos for advertising and promotional purposes.

Patient Signature:

Date:

Photo/ Video Consent Form

Restorative Health

Photo & Video Consent Form

Section 1: Medical Consent (Required)

Section 2: Marketing & Advertising Consent (Optional)

Patient Acknowledgment