Consent to Release
I, the undersigned, do hereby grant to Sullivant Dentistry and/or our Website Administrator (Brooks Jeffrey Marketing Inc.) the right and license to use and to authorize use of patient testimonial information and any photos of me taken at Sullivant Dentistry and grant the same right for all photos taken by me and/or supplied by me to Sullivant Dentistry, for any purpose related to Sullivant Dentistry; to edit, crop, and incorporate the testimonial information and images into any production related to Sullivant Dentistry, at the discretion of Sullivant Dentistry, in any manner or media, in its public relations and marketing campaigns.
I understand that I am providing the testimonial information to Sullivant Dentistry and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).
I waive the right of prior approval and hereby release Sullivant Dentistry and its agents and assigns from any and all claims for damages of any kind based on the use of my testimonial or information in the testimonial.
Right to revoke: I understand I have the right to revoke this Release at any time by providing written notice of my revocation and submitting it to Sullivant Dentistry. I understand that revocation of this Release will not affect any action Sullivant Dentistry took in reliance on this Release before receiving my revocation.
By signing below, I agree and acknowledge that I have read and understood this Release and agree to all terms described. I am of legal age and freely sign this Patient Information/Photo Release for Sullivant Dentistry and/or its agents and assigns.