Social Media Consent Form

First Name

Email

Middle Name

Phone

Last Name

Date of Birth

Street Address

City

Postal / Zip code

Country

Authorisation and Consent

Can we use your Name *

Full Name

First Name

Nickname

Anonymous

Can we use your photos to post in *

Website

Facebook

Instagram

All of the above

I authorise Bright Smiles Orthodontics to use my Before and After treatment photos for Advertisement and Marketing Purposes.

I authorise Bright Smiles Orthodontics to use my Before and After treatment photos (Teeth Only) for Advertisement and Marketing Purposes.

I am of legal age or minor and represented by my parent/guardian

I understand I will not receive any monetary compensation.

I declare that the information I have provided is accurate & complete

Name of Patient, Parent or Guardian

Signature

Thanks for submitting!

Address

Contact

Follow

bottom of page