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I,
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hereby authorize
Dr.
or his assistants to take photographs, slides, and/or videos of my face, jaws, mouth, 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 study club meetings, lectures, seminars, demonstrations, and professional publications (journals, magazines).
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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 will be kept confidential.
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I do not expect compensation, financial or otherwise, for the use of these photographs.
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