THPDental - Consent For Medical Photography

Personal Information

Date of Medical Photography*

First Name*

Last Name*

I consent to medical images and / or video being made of me. I agree that duplicates may be made for the referring doctor as well.

I AGREE that the images may be:	YES	NO
Placed in my medical record for future treatment
Used by health professionals for education and training
Used in paper or electronic health professional pubications
Used in clinic education materials

If so, the pictures will show my whole face
If so, the picture will show my lower face ONLY, i.e. the part below the nose. Upper face will be covered or not being shown at all
If so, the pictures will show my teeth ONLY. No other part of my face will be shown.

CONSENT

By signing below, I confirm that I understand this consent form.