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Publication of Records:
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In regards to the person named above, if not himself or herself, I hereby authorize photos, x-rays or any other recorded material created during the care and treatment or after its completion to be used for either the advancement of dentistry or in promotional materials. These include educational, research-related, public service, and promotional purposes. This may include, without limitation, uses such as: inclusion on a website, brochures and other publications in print or electronic media, catalogs, press releases.
The person's identity will not be revealed to the general public. To be more specific, full face photos, date of birth, address, social security number and other identifying information ARE NOT INCLUDED IN THE RELEASE above and cannot be divulged.
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State relationship to person above if not an adult:
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