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Media Release
Here is a sample all media release that you may have your patients sign when included in any video, audio or still picture. Please keep your file of all releases in a safe place. Please note that this is only a sample. Please check with the laws in your jurisdiction before using.
All Media Release Form
Name: ________________________________________________
I hereby consent for (name of your dental office/doctor) to use, reproduce, exhibit or distribute (in full or in part) any photographic, video, film, and/or audio recordings made of me or my likeness; and/or any written extract of such recordings in which I may be included, for any purpose whatsoever, in any medium now known or in the future invented.
I hereby release, discharge, and agree to hold harmless (name of your dental office/doctor goes here) and all persons acting under its permission or authority from any liability or injury that may occur while performing or appearing in the said video, audio, or photographic production.
Talent Signature: ____________________________________________
Talent Print Name: ___________________________________________
Date: _________________________
Address: ___________________________________________________
City: ______________ State: __________________ Zip:___________
If talent is a minor under the laws of the state where acting or performing is done:
Legal Guardian: ______________________________________________________
(Print name)
Signature: ____________________________________________________
Date: ________________________________
Address: ___________________________________________________
City: ______________ State: ________________ Zip: ___________
