This Release and Photo Image Publication Consent Verification is entered into between Calcagno Cosmetic and Family Dentistry with its principal place of business located at 1801 Greenview Drive SW Suite 101 Rochester, MN  55902.

This agreement is for the purpose of identifying any express or implied agreement, including, but not limited to, permission, consent, release, and/or authorization between Calcagno Cosmetic and Family Dentistry and patient in connection with dental services patient received from Calcagno Cosmetic and Family Dentistry and/or Calcagno Cosmetic and Family Dentistry’s associate.

Calcagno Cosmetic and Family Dentistry and patient warrant and represent that the patient has given consent and full authorization that any photographs and/or images of the patient and/or patient’s mouth, under the following conditions:

 

  1. The photographs and/or images will be taken by Calcagno Cosmetic and Family Dentistry or by a photographer and/or skilled operator approved by Calcagno Cosmetic and Family Dentistry.
  2. The photographs and/or images may be used for:
    • dental records, and if in the judgment of Calcagno Cosmetic and Family Dentistry, dental research, education will be benefited by their use, such photographs and/or images and information relating to patient may be published or republished, either separately or in connection with each other, in, but not limited to, professional journals, dental based Internet web- sites, or any other purpose which Calcagno Cosmetic and Family Dentistry may deem proper in the interest of, but not limited to dental education, knowledge, or research; and/or
    • Patient further authorizes that the photographs and/or images may be used by Calcagno Cosmetic and Family Dentistry or by any entity approved by Calcagno Cosmetic and Family Dentistry in promotional printed, computer web-site, and/or video material.
  3. At no time will patient’s name, address, or any other alpha/numeric patient identifiable information be used in connection with the publication of the photographs and/or images of patient.  Patient acknowledges the possibility that his/her identity may become known as a result of the publication and use of the photographs and/or images described in paragraph 2. above.
  4. The photographs and/or images may be modified and/or retouched in any way in Calcagno Cosmetic and Family Dentistry’s discretion.

By checking, certifies that he/she has read and understood each and every section of this Agreement, and agrees to be bound by its terms.

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