I understand that Exceptional Dentistry may take or receive photographs, video, audiotape and other image and sound-based media of its office, including its employees and other visitors. The company may wish to use such media for educational, promotional, advertising, and other purposes. This permission for release, without compensation or prior notice, would allow the company to use media in its printed publications, during presentations, and otherwise.

Therefore, I herby freely and voluntarily consent to the use and publication of my name, participation, picture, or likeness by the company or its employees or agents for any and all purposes including, but not limited to educational, promotional, advertising, and trade through any medium or format, including but not limited to, videotape, audiotape, film, photograph, television, radio, digital, internet, theater, or exhibition, at any time from this date forward until I revoke this consent in writing. I further waive any claims against the company, its employees, or agents based upon or related to its use or publication of my likeness, voice, participation, or picture. I freely give this authorization without expectation of compensation.

By signing below, I agree to the terms outlined in this release.

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