HIPAA Media Release

If you're reading this that means you are considering letting us use your image or video to share with the world! We sincerely appreciate your participation!! The team at Medical Arts Dental takes your experience very seriously. We are committed to providing the highest level of care and creating a comfortable, friendly environment that promotes health and wellness. Hopefully your story helps others get the care they need. Together we can help make people smile.

To ensure that Medical Arts Dental is cooperating in accordance with your interests, and using your personal information with your authorization, we ask you to sign this release.

Please review the necessary formalities below. If you have any questions please let us know.

I hereby voluntarily and without compensation grant permission to Medical Arts Dental for unrestricted use of the photographic/video images(s) taken of me, or of anyone for whom I have legal responsibility - effective on this date, for any official/unofficial publication, presentation, exhibit, video, or other print or digital format. I further grant to the Medical Arts Dental full rights to republish, without time restriction, these images. Medical Arts Dental may use audio, video and photographic materials internally or externally in communications, publications including but not limited to- social media, website, news letter, radio, magazines, news papers or other publication. I further extend my permission to Medical Arts Dental to provide these images to the media as part of any business. By signing I represent that I am myself or the legal parent, personal representative, or guardian of the named individual and I am not prohibited by Court Order from releasing access to the requested information. I grant Medical Arts Dental the right to disclose specifics about my visit including but not limited to: reason for the appointment, duration of appointment, how long I have been a patient, services rendered, providers worked with and more. I acknowledge that this permission authorizes Medical Arts Dental to post my testimonial statement, voice, picture, name, and likeness on third party social media web sites (including but not limited to Facebook, Twitter, Instagram, and YouTube), which may require Medical Arts Dental to grant the owners and users of such sites a broad license to use such materials for any purpose without notice to or approval from me. I understand that I will not have any right to compensation or reimbursement in connection with the use of my name, image, verbiage, or likeness.

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