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Sacramento Natural Dentistry


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Patient Photo Release Form
* I hereby authorize Dr. Azouz 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
Baseline records
Demonstrations
Professional publications (dental magazines and journals)
Advertising
* I do not expect compensation, financial or otherwise, for the use of these photographs.

Patient Consent Form for Video/Digital Recording for Training Purposes

We are hoping to make video/digital recordings of the consultations/treatments between you, our patient, and Dr. Darryl Azouz, whom you are seeing today. The videos are used by the doctor for the purpose of review and documentation of your treatment. The video/digital recording is ONLY of you and the doctor talking together. All video/digital recordings will be stored securely in line with the practice guidelines. You do not have to agree to you consultation with the doctor being recorded. If you want the camera turned off, please tell - this is not a problem, and will not affect your consultation in anyway.
TO BE COMPLETED BY PATIENT
I have read and understood the above information and give my permission for my consultation/treatment to be video recorded.
Patient Name:
Place of Video Recording:Office of Dr. Darryl Azouz
Details of the person accompanying patient to the consultation:
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)