Photo Release

We value our patients' right to privacy and confidentiality, and we take our responsibilities under HIPM and the Texas Medical Records Privacy Act very seriously. Our practice exercises great care in the use of patient images and patient identities.

By signing below, you understand that this authorization may be revoked at any time merely by notifying our office in writing that you wish to no longer allow your photographs to be shared.

Your willingness to allow photography release will have no effect on the treatment or care you receive from our office and staff.

I give my permission to Dr. Ace Jovanovski and Jovan Prosthodontics to use my diagnostic photographs, radiographs, and study casts for diagnostic and educational purposes. These items may also be shared with referring dentists, doctors, and colleagues, for diagnostic and educational purposes.

I give my permission to Dr. Ace Jovanovski and Jovan Prosthodontics to use my before and after photographs to publish in internet illustration, promotional, editorial and advertising in photographs and details of my treatment without restrictions as to alteration.

I give my permission to Dr. Ace Jovanovski and Jovan Prosthodontics to use my photographs in social media publications and brief descriptions.

I do not give my permission to share any photographs taken by Dr. Ace Jovanovski or Jovan Prosthodontics to any outside providers or publications.

Date

E-Signature

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