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I hereby authorize Dr. Azouz and/or any of his assignees to take
photographs, slides, and/or videos of my face, jaws, and teeth.
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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).
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I further understand that if the photographs, slides, and/or videos are
used in any publication or as a part of a demonstration, my name
, or other identifying information could be used unless
stated differently below. I do not expect compensation, financial or
otherwise, for the use of these photographs.
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I do not mind if my first name, face, and teeth are used in any of the above stated situations. Exceptions:
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