Printable Consent Form

PHOTOGRAPHY & SOCIAL MEDIA / MARKETING USE

Indy Smile Group uses clinical photographs, videos, and radiographs (x-rays) for documentation of your dental condition and treatment, treatment planning, communication with other healthcare providers, and for educational and marketing purposes (including our website, social media platforms such as Instagram, Facebook, TikTok, YouTube, Google, and printed materials).

WHAT WE MAY USE

• Intraoral and extraoral photographs of your teeth, smile, and face
• Before, during, and after treatment images
• Short video clips of procedures or patient testimonials (with your separate verbal/written approval when possible)
• Digital scan images or 3D renderings

HOW IMAGES MAY BE USED

• Internal patient records only (always permitted)
• Educational purposes for staff, students, or professional presentations
• Marketing and advertising: website, social media, Google Business, direct mail, brochures
• Before-and-after galleries (your images may be used alongside others)

Images will not include your full name, address, or other direct identifiers unless you specifically authorize testimonial use with attribution. We make reasonable efforts to protect your privacy.

YOUR RIGHTS

• You may decline photography consent entirely or limit use to internal records only.
• You may revoke this consent at any time by written notice; however, images already published or distributed cannot always be fully retrieved or deleted.
• You will not receive compensation or royalties for the use of your images.
• You have the right to review any photos taken and request deletion from our marketing library (not from your medical record).

PATIENT ACKNOWLEDGEMENT

• I consent to photographs, videos, and digital images being taken as part of my dental care and records.
• I consent to the use of my images for internal clinical purposes and communication with other providers.
• I consent to the use of my images for marketing, educational, and promotional purposes by Indy Smile Group (website, social media, print, etc.).
• I understand that I will not be identified by name in public marketing materials unless I separately authorize a testimonial.
• I understand that I may revoke marketing consent at any time, but previously published images may remain in circulation.
• I have had the opportunity to ask questions about how my images will be used.

Optional - I prefer my images to be used for clinical records ONLY and NOT for any marketing or public use.

• I decline marketing / social media / website use of my images.

PATIENT / GUARDIAN ACKNOWLEDGEMENT AND CONSENT

I have read (or had read to me) and understand this consent form. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the proposed treatment. I voluntarily consent to the treatment described above.