Media Release Form(s)

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.

Download PDF – Media Release Form

The form below gives consent for use of patient name, picture & related information for office website, social media & newsletter.

Patient Name*
Patient Email*
Patient Phone Number*
Street Address*
City, State, Zip*
Patient Number
- Unknown
Purpose of Consent: By signing this form, you are consenting Andros Orthodontics, Inc. the right to display the above patient’s name, picture and any related information on the office bulletin boards, social media and on the office website at www.androsorthodontics.com.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation.
I have had full opportunity to read and consider the contents of this consent form. By checking this box I am agreeing that all information listed above is correct, and giving my consent to the terms listed above.*
- I agree
Your Name*
Date*
Relationship to Patient*

Revocation of Consent

Patient Name*
Patient Email*
Patient Phone Number*
Patient Number
- Unknown
*
- I revoke my Consent for your use and display of patients name, picture and related information for bulletin boards, social media or website for the office of Andros Orthodontics, Inc. I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation.
Date*

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