Frost Orthodontics

Ormco Image Consent and Release Form


ORMCO Image consent and release form

 

I give my consent and permission to Ormco Corporation, and its affiliates and permitted assigns ("Ormco") and each of Ormco's employees, officers, agents and contractors ("Ormco Representatives"), using my Image in Ormco's Publications without payment or any other consideration. 

 

Without limitation, Ormco and Ormco's Representatives may exhibit, publish, reproduce, adapt or distribute my Image as they think fit in any form (in whole or in part) and by any medium for the purposes of publicizing Ormco and I waive any right to inspect or approve any Publication of my Image.

 

My "Image" includes my name, photograph, appearance, character, image (including Case Images), likeness, other personal characteristics and any testimonial that I may provide.  "Case Images" include intraoral, extraoral and software treatment plans and details of any treatment specific to my orthodontic case.  "Publication" includes any social media, online, electronic and print publications and publications for any lawful purpose including Ormco's educational, advertising, promotional and marketing purposes. 

 

I consent to Ormco and Ormco's Representatives collecting, storing, handling, accessing, managing, transferring, using and disclosing my personal information for the purpose of using my Image and any other lawful purpose.

 

I understand and agree that all material containing my Image and all intellectual property rights in that material (including copyright) is the property of Ormco Corporation immediately on its creation and will not be returned.

 

I release Ormco and Ormco's Representatives from any claim I may have against them or liability they may have to me, now or in the future for compensation (monetary or otherwise) for the right to use my Image or arising in any way in connection with their use of my Image including claims based on libel, breach of privacy, or copyright.

 

I have read the above consent and release and fully understand the contents thereof.

 

Printed (Patient) Name:                 _____________________________________________

Institutional Affiliation:    _____________________________________________

Date:                             _____________________________________________

 

Note: If you are under 18 years of age, your parents or legal guardian must print their name below and sign.

 

Parent/Guardian name:     ________________________________________________

Leave this empty:

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Signature Certificate
Document name: Ormco Image Consent and Release Form
lock iconUnique Document ID: 457e76af445bf78407412616b5a8e36f14fde6da
Timestamp Audit
February 4, 2021 10:08 am MSTOrmco Image Consent and Release Form Uploaded by Stuart Frost - smiles@frostortho.com IP 72.215.202.99