Optional · Not required for treatment
Photography & Videography Consent
for clinic marketing and publicity
Patient:
Age / Sex: / Female
Date: 9 October 2026
Recording: Photographs and video
Guardian: —
Appearance: Face and identifying features may be shown
1. Purpose
I give permission to [Clinic name] to take photographs and video recordings of my teeth, smile and treatment, including before-and-after images, and to use them to promote the clinic's services.
2. Where it may be used
The photographs and video recordings may be used on the clinic's website, social media pages (such as Instagram, Facebook and YouTube), printed brochures, posters, clinic displays and paid advertising. My face and other identifying features may be visible. My name will not be published unless I agree to it separately.
3. Your rights
I understand that I will not receive payment for this use, that the photographs and video recordings remain the property of [Clinic name], and that once published online they may be copied or shared by others beyond the clinic's control.
4. Duration and withdrawal
This consent lasts: until i withdraw consent. I may withdraw it at any time by telling the clinic in writing; the clinic will then stop new use, although material already printed or shared cannot always be recalled. Refusing or withdrawing this consent will not affect my dental treatment in any way.
Tick each place you agree to — leave blank to refuse
Clinic website
Social media
Printed brochures / posters
Paid advertising
Before-and-after gallery
Clinic displays / screens
I have read and understood this form, I have had the chance to ask questions, and I give this consent voluntarily. I understand it is separate from, and not a condition of, my dental treatment.
Patient signature
Name: ______________________
Parent / guardian signature
Name: ______________________
Clinic representative
Name: ______________________
A copy of this consent will be kept with the patient's record. Review against local data-protection rules before use.