Claremont | 08 9384 6855 Jandakot | 08 9414 1470

Photographic Consent

We are extremely proud of your orthodontic treatment outcome and would like to share your pre and post treatment photographs. We have the highest respect for the privacy of all our patients and in accordance with our Privacy Policy are kindly requesting that you provide consent prior to publishing patient photographs, including on social media. If you would be willing to kindly participate, please complete the consent form below.

 

 

If the Patient is under 18 years of age:

 

I voluntarily consent to the use, publication and copyright of the patient’s photographic images for general advertising, publicity and promotional purposes by Orthodontics on Berrigan or Orthodontics on St Quentin, including on social media, to demonstrate the orthodontic treatment outcomes delivered by Dr Siva Vasudavan and his team. I understand that a patient’s face may be identifiable in the photographic images and the promotion/post may include commentary as to the specific diagnosis and issue which was addressed during the course of treatment. I hereby grant Dr Siva Vasudavan a royalty-free licence to use the patient’s images and understand the patient will not receive payment for the use of such photographic images.
YesNo

 

The patient and/or I consent to be tagged in any social media posts when the patient’s photographic images are posted.
YesNo

 

 

The patient would like to be involved in future photographic and/videography shoots at either Orthodontics on St Quentin or Orthodontics on Berrigan.
YesNo