Testimonial & Photo Release Consent Form

I grant permission to AARON SCHAMBACK, DDS, PA and its agents or employees, to use photographs/testimonials taken of me for use in office publications including but not limited to brochures, newsletters, and magazines, and to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on web sites or other electronic forms or media, without notification to me or any other person.

I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph, and if signing on behalf of the minor named below, I waive all such rights on behalf of the minor named below.

I hereby agree on my own behalf, to release, defend, and hold harmless AARON SCHAMBACK, DDS, PA. and its agents or employeees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production or the finished product, its publication or distribution.

I am 18 years of age or older and I am competent to contract in my own name I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.