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Patient
Media Release

I, (patient or parent or legal guardian) hereby authorize Smile Brands Inc. and its affiliates, licensees, successors and assigns (collectively, “Smile Brands Inc.”) to record, tape, film, photograph, digitize or otherwise preserve in permanent form my name, likeness, image and voice, as well as my letters, signature, story and statements (collectively, “Recordings”) relating to my (or the minor below) dental and medical history, diagnosis and treatment.

I agree that Smile Brands Inc. may use and reuse such Recording, in whole or in part, for any purpose, including, without limitation, education, promotion, public relations and publicity. Smile Brands Inc. may do so through any means, including, without limitation, internal or external newsletters, audio or video broadcasts, online websites, publications, advertisements, and other promotional and public relations materials, as well as through newspapers, radio, television, the internet and other print and electronic media. I agree that all Recordings shall be owned by and shall be the sole property of Smile Brands Inc., and that it may copyright all material containing the Recordings. I agree that if I should receive any print, negative or other copy of the Recordings, I shall not authorize their use by anyone else. I agree that no advertisement or other material need be submitted to me for any further approval and that Smile Brands Inc. shall be without liability to me for any distortion or illusionary effect or adverse result to me on account of the publication of my picture, portrait or likeness, except where prohibited by law.

I agree that I shall have no claim to compensation and no claim against Smile Brands Inc. based on invasion of privacy, defamation or right of publicity for use and/or publication of the Recordings or my picture, portrait or likeness. I hereby release Smile Brands Inc. from any and all claims based upon the use of the Records, including any claims under HIPAA.

I warrant and represent that this license does not in any way conflict with any existing commitment on my part. I have not authorized anyone prior to this Release, nor will I authorize or permit the use of my name, picture, portrait, likeness or testimonial statement in connection with the advertising or promotion of any product or service competitive to or incompatible with Smile Brands Inc.

Nothing in this Release will constitute any obligation on the licensed parties to make any use of any of the rights stated within.

I understand that I am not required to sign this authorization. Smile Brands Inc. does not condition treatment, pricing or financing on the signing of this form. I can request a copy of this authorization be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of any information and audio/video/photographic material.

I am aware that my protected health information will exist forever in either a recorded, printed, and/or electronic version or other version as may develop over time and that once it is published or disclosed in any form it will continue to be used. I understand that information about me used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state law.

I understand that I may revoke or withdraw this permission at any time to prohibit future use of my information, and to request that audio/video recording, filming, or photographing cease at any time. To do so, I must send written notice to Smile Brands Marketing Department at 100 Spectrum Center Drive, Irvine, CA 92618.I understand that Smile Brands Inc., as well as other persons or entities, will retain copies of any such electronic or printed versions.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREED TO THE TERMS OF THIS AUTHORIZATION.

NOTE: By submitting the form below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Patient name(Required)
Parent or Legal Guardian Name (if applicable)
Email(Required)
Consent options(Required)
By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
This field is for validation purposes and should be left unchanged.