You may fill out the Media Release Form online and submit it to our office, or download, print, and fill out a PDF copy of the form to bring with you to your next appointment. If you have already submitted a Media Release Form, and wish to revoke your consent, scroll down to submit a Revocation of Release.
The form below gives consent for use of patient name, picture & related information for office website, social media & newsletter.
Revocation of Consent
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