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PHOTO AUTHORIZATION RELEASE

PHOTO AUTHORIZATION RELEASE

Dr. Dan Peterson

1415 Sage Street

Gering, NE 69341

www.dentalgentlecare.com

I hereby authorize Dr. Peterson and staff to use the photo's taken of my face and smile.  These pictures may be used for educational purposes for both staff and other patients, both in the office and on the web-site.  I understand that my name will NOT be used.

 

Name:

Signed:

Date:

 

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PLEASE NOTE: The information contained herein is intended for educational purposes only.  It is not intended and should not be construed as the delivery of dental/medical care and is not a substitute for personal hands on dental/medical attention, diagnosis or treatment.  Persons requiring diagnosis, treatment, or with specific questions are urged to contact your family dental/health care provider for appropriate care.
This site is privately and personally sponsored, funded and supported by Dr. Peterson.  We have no outside funding.
Confidentiality of data including your identity, is respected  by this Web site. We undertake to honor or exceed the legal requirements of medical/health information privacy that apply in Nebraska.

Copyright 1998-2017 Family Gentle Dental Care, all rights reserved.