Consent to Photograph/Video Photo/Video Feedback Release

Authorization

I, the undersigned, give permission to Jehangir Oracare Dental Centre to photograph/

video me and use such photograph(s)/video(s) in all forms of media, for any and all
promotional purposes including advertising, display, audiovisual, social media
platform or editorial use.

I further consent to the use of my name in connection with the photograph(s)/video(s)

if needed by the Jehangir Oracare Dental Centre.

I understand and agree that I will not receive any payment for my time or expenses or
any royalty for the publication of the photograph(s)/video(s) or the use of my name
and I hereby release Jehangir Oracare Dental Centre from any such claims.

I have understood the aforesaid/ the above writing has been read out to me in a
language I understand and I am willing to give my consent.

Signature/
Name (with relation) Date & Time
Thumb
Patient or

Next of Kin
Reason for Next of Kin
consenting
Witness
Doctor
Interpreter (if required)