Media Consent

Want an appointment?

Fill Out the Form Below or Download the PDF​

    Diagnostic Records Consent

    I, hereby authorise The Periodontists to take photographs, and videos of my teeth, jaws, and face. I understand that the photographs, and videos will be taken as part of my periodontist is able to provide optimum care for my periodontal health.

    Media Release Consent

    This media may be used for communication with other health care professionals, educational publications (dental journals), and educational lectures.

    The content may also be used for advertising purposes (including website publication, Facebook posts, etc.)

    I further understand that if the photographs, and videos are used in any publication or as part of a demonstration, my identifying information (first name only) could be used unless stated differently below.

    I do not expect compensation, financial or otherwise, for the use of these photographs.

    If I wish to revoke this consent, I may do so in writing. Please choose one option (if declining the ‘Media Release Consent’, leave
    blank and sign):

    Download PDF

    Scroll to Top