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.

  • By providing a mobile number, I agree that Andros Orthodontics may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.
  • 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.

Revocation of Consent

  • By providing a mobile number, I agree that Andros Orthodontics may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.

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