Craniofacial Treatment Photo Release Form
Please complete this form to authorize the use of craniofacial treatment photos for the purposes described in the release. Do not include sensitive identification or financial information.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian Full Name
First Name
Middle Name
Last Name
Relationship to Patient
Preferred Contact Method
*
Email
Phone
Text
Mail
Photo Release Authorization
Consent Terms
Consent Acknowledgment
*
I agree
I do not agree
Use Restrictions (optional)
Signature and Date
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: