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Photo Release

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  • 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,
  • 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.

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