Click on Calendar, type the year 'YYYY' and pick the month & date.
Willow Point Dental P.C.

  Last name

  Mid name

  First name

Photography/Video Consent Form

* I, , hereby authorize Joseph A. Narde, D.D.S. and Willow Point Dental to take photographs of my face, jaws and teeth.
* I understand that the photographs/videos will be used as a record of my treatment and care. They may also be used for demonstrations to other patients and dentist, as well as "before and after" pictures for our website and advertisements.

Emergency Contact

In Case of Emergency Please Call -
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*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)