Image Release Form The Guter Center for Family & Cosmetic Dentistry Inc. would like to use patient images on its Web site. Occasionally, it might be necessary to use the first name of a patient, but no last names, addresses, and/or telephone numbers will ever be used. We/I hereby give permission for The Guter Center for Family & Cosmetic Dentistry Inc. to use photos along with first name on their Web site and other forms of communication. We/I hereby give permission for The Guter Center for Family & Cosmetic Dentistry Inc. to use images only without first name on their Web site and other electronic forms of communication. We/I hereby do not give permission for The Guter Center for Family & Cosmetic Dentistry Inc. to use photos on their Web site and other forms of communication. Patient’s Name* First Last Signature*(Parent or Guardian of minor patients is required)Date* MM slash DD slash YYYY *Please note, if you are a new patient and have signed this release form; your full name (first and last) will be printed in the next edition of our newsletter and will be listed on our Web site to recognize you as a new patient. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
