Media Release form
Bunker Hill Pediatric Dentistry uses photographs or written material from our employees, patients and patient’s parents or guardians to promote the further success of our practice as well as to maintain a connection outside of the office with those who visit us. We seek the consent of you, the (employee/parent/guardian), prior to using, displaying or releasing:
1.) You or your child’s name, photograph, picture, image or likeness
2.) You or your child’s quote or written material
By signing this form, you are consenting for the use of written material, photographs, audio, video, or electronic images of the above individuals concerned to be used by Bunker Hill Pediatric Dentistry, PLLC for publication, publicity material, advertising, video, audio, or other electronic media such as the internet.