Authorization and Release of Testimonial Information

Patient Testimonial, Video, Photo, Audio Release Consent Purpose of Consent: You are hereby consenting to allow Lakeshore Family Dentistry to use and disclose your testimonial, audio, photos and/or videos and you acknowledge that they may be distributed to the public.

Right to Revoke: You have the right to revoke this Release at any time by providing written notice of your revocation and submitting it to the Contact Person listed below. Please understand that revocation of this release will not affect any action Lakeshore Family Dentistry took in reliance on this release before receiving your revocation.

CONSENT TO RELEASE I hereby authorize Lakeshore Family Dentistry and staff to use my testimonial, photos, videos, audio and any information contained herein in its media/public relations efforts. I understand and approve the disclosure of the testimonial, photo, video, audio information to the media and other individuals and entities that may be involved in the media/public relations efforts of Lakeshore Family Dentistry. I understand that I am providing the testimonial, photo, video, or audio information to Lakeshore Family Dentistry and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). I waive the right of prior approval and hereby release Lakeshore Family Dentistry from any and all claims for damages of any kind based on the use of my testimonial, picture, video, audio or information in the testimonial. I agree and acknowledge that I have read and understood the above Release and agree to all terms described. I am of legal age and freely agree to this Consent to Release my Patient Testimonial and other media I provided to the doctor.

I understand my testimonial as outlined above (the “Testimonial”) and made on behalf of Lakeshore Family Dentistry (hereinafter called “Lakeshore Family Dentistry“) may be used in connection with publicizing and promoting Lakeshore Family Dentistry. I authorize Lakeshore Family Dentistry to use my name, brief biographical information, and the Testimonial as defined on this form.

I hereby irrevocably authorize Lakeshore Family Dentistry to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing Lakeshore Family Dentistry’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against Lakeshore Family Dentistry for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears.

I hereby hold harmless and release Lakeshore Family Dentistry from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.


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Glendale:  414-352-1600 or Greendale:  414-421-2303


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