Photo & Marketing Release

I understand I am not entitled to any compensation, royalty, or other payment for the use of my image or testimonial. This release is voluntary.

I understand that California Civil Code § 3344 gives me the exclusive right to control the commercial use of my name, voice, photograph, and likeness. By signing this release, I voluntarily authorize the practice to use my image and likeness for the marketing purposes and on the channels I have selected above, and I waive my right to bring a claim under Civil Code § 3344 for those specific authorized uses during the duration I have selected. This waiver does NOT apply to uses outside what I have authorized, and does NOT prevent me from revoking this release in the future for future uses.

I understand this release constitutes my written authorization under HIPAA (45 CFR § 164.508) for the practice to use my protected health information (including images and testimonial) for marketing the practice. The practice will NOT receive direct or indirect payment from any third party in exchange for using my image (no paid endorsements or sponsored content involving my likeness without a separate written agreement).

I understand my dental care, treatment outcome, and standing as a patient are NOT conditioned on signing this release. I can decline without any impact on my care.

I understand I can revoke this release in writing at any time by notifying the practice. Upon receipt of a written revocation: (a) the practice will remove my image from its website, social media accounts, and other practice-controlled digital channels within 30 days; (b) the practice will not include my image in any new print runs, advertisements, or distributions; and (c) the practice cannot recall print materials already distributed or copies already saved by third parties (such as platform users or search engines), but will make reasonable efforts to request removal from third-party platforms.

I understand the practice may crop, color-correct, or otherwise edit images for clarity or layout, but will not digitally alter clinical features (teeth, gums, etc.) in a misleading way.

I understand the practice will not directly sell or license my image to unrelated third parties for their own marketing. However, I understand that posting images to third-party platforms (such as Facebook, Instagram, or Google) is subject to those platforms' terms of service, which typically include broad licenses allowing the platform to host, display, and redistribute content. The practice has no control over and is not responsible for these platform terms.