Photo and Video Testimonial Release Form

Photo & Video Testimonial Release Form

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
I give permission to use