Social Media Release - Boca Raton Orthodontist

Patient Name

First Last

Legal Guardian Name

Want to be tagged in pictures and stories?*

Yes please 🙂
No thanks, let’s keep it private.

Leave us your instagram handle! @__________

I consent to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Dr. Pamela Steiger for any lawful use deemed appropriate, including treatment, advertising her services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes. I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Dr. Pamela Steiger during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials. I have read the foregoing in its entirety and understand its terms.

Social Media Consent*

I agree to the above policy.

Patient or Legal Guardian Signature

Print Name of Patient or Legal Guardian

Date