4th & Seneca Logo Seattle, WA

Completion of this form in it's entirety is optional at time of visit/treatment

Patient Authorization to Use or Disclose Photography/Video

I, (the patient) authorize Dr. Vo and Associates to take and or reproduce photographs/video of my teeth or face for educational material, marketing material, and/or dental lectures and presentations.

Information to be used or disclosed: Photographs, video and/or electronic media.

Your privacy is important to us.

This authorization for release of records will not release the following specially protected information: Reproductive Care (applicable to minors only), Sexually transmitted diseases, mental health, drug and alcohol treatment and/or HIV/AIDS.

Expiration of Authorization:

This authorization expires when there is a written request from the patient to terminate this authorization.

By signing this page, I acknowledge that I have read and agreed to the terms of this agreement.

Signature (Patient or Person Authorized to Give Authorization):

Use your mouse or finger to draw your signature above

Potential for Re-disclosure: Once disclosed, the law does not always require the recipient of your information to keep it confidential.

Revocation: This authorization may be revoked by submitting a request in writing to:

Dr. Vo & Associates
1119 4th Ave
Seattle, WA 98101

Note: A request to revoke this authorization will not affect any actions already taken based on the original authorization, or prevent Dr. Vo from requiring the information in order to be paid for treatment that you receive.

I understand I have the right to:

• Inspect or to receive a copy of my protected health information

• Receive a copy of this signed form

• Refuse to sign this form for authorization to disclose or release my protected health information.

I also understand Dr. Vo will not base treatment or payment decisions on receipt of this signed authorization.