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Photo Release

  • Ask The Doctor

 Photo Release

  • Patient Photo Release Form

  • I hereby authorize Dr. Wall and/or any of his assignees to take photographs, slides, and/or videos of my face, jaws, and teeth.

    I understand that the photographs, slides, and/or videos will be used as a record of my care, and may be used for educational purposes in lectures, demonstrations, advertising (including website publication, newspapers, magazines, phone books, television), and professional publications (dental magazines and journals).

    I do not expect compensation, financial or otherwise, for the use of these photographs,
  • Date Format: MM slash DD slash YYYY

After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

Schedule Your Appointment with the Holistic Dentist

Every service we offer is aimed at improving your overall health. We offer several procedures that eliminate the need for surgical incisions, reducing your discomfort, downtime, and the need for multiple visits. Call our office to schedule your consultation today.