Photo and Video Testimonial Release Form Photo & Video Testimonial Release Form Name * Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Phone * I hereby grant permissions to Dr. Jamila D. Miller, D.D.S., L.L.C., to use my photographs and/or video testimonials I give regarding the dental care I received from any such office, in any marketing or teaching materials. My photographs and/or video testimonials can be used to market and/or advertise her dental practices, including use on Dr. Jamila D. Miller’s web site and social media platforms. I acknowledge Dr. Jamila D. Miller’s right to crop or otherwise treat the photographs and/or video testimonials at her discretion. I also acknowledge that Dr. Jamila D. Miller may choose not to use my photographs and/or video testimonial at this time, but may do so at her own discretion at a later date. I also understand that once my images are posted by Dr. Jamila D. Miller to her web site and/or social media platforms, the images can be downloaded by any computer user, which is beyond the control of Dr. Jamila D. Miller, and I will hold her and any of her affiliated offices harmless from any such use or downloads. I hereby freely and voluntarily consent to the use of my photographs as stated above until I revoke this consent in writing. I authorize photos of the following to be used as stated above. Please check the appropriate options below. I authorize photos of * My entire face My entire face with eyes blacked out My mouth/teeth only I give permission to use * My full name My first name only My initials only No name Signature for Photo Consent signature keyboard Clear Date Signature for Video Consent signature keyboard Clear Date Captcha Submit If you are human, leave this field blank.
