Form

KIDS DENTAL CARE PHOTO WAIVER AND CONSENT

I do hereby authorize and consent to the use of certain photographs/x-rays
of me taken by KIDS DENTAL CARE. I hereby grant them permission to reproduce, publish, print, use and distribute copies of such photographs/x-rays either in an official medical publication or in the form of prints, slides or
film for use in connection with articles, social media and lectures dealing with jaw or dental disorders.

First Name

Last Name

Date Of Birth

Parent/ Legal Guardian First Name

Parent/ Legal Guardian Last Name

Address

City

Zip Code

Patient/Legal Guardian Signature

Date