From time to time our practice features patients in clinical presentations, new patient consultations and for advertising/marketing purposes. By signing this release, I hereby give Alizadeh & Schreiner Orthodontics and all persons and companies acting with their authority permission to copyright, use, re-use, publish, and/or re-publish, any and all photographic portraits, pictures and/or video graphic pictures or recordings of me and/or my minor child(ren) listed below, or audio recordings of my voice or the voice(s) of my minor child(ren) listed below, or in which I am (or they are) included, without restriction. I also consent to the use of printed matter in conjunction therewith. I have read the above Release and Authorization, and I am familiar with the contents thereof.
Patient First Name:         Patient Last Name:    
Responsible Party Name:    
I release and authorize the above including the use of my and/or my minor child(ren)'s name.