Patient Social Media Consent Form Name * First Name Last Name Date of birth? * MM DD YYYY Authorisation, Release and Consent * Can we use your name? First Name Nickname Anonymous Do you want to be tagged? If yes, please provide social handle Please accept the terms below * I authorize and grant De Necker Dentistry to take my photos regarding my experiences with them. I grant De Necker Dentistry to use my photos on Facebook, Twitter, Instagram, and other social media platform. I allow De Necker Dentistry to edit, alter, copy, or distribute the photos for social media advertising and marketing. I agree that the photos belong to De Necker Dentistry. I understand that I will not receive any monetary compensation. Digitally Signed by: * Your submission will be saved in your patient file Thank you! We have received your consent form.
