Photo Authorization & Release Form

I hereby expressly grant Gluck Orthodontics and its employees, agents, and assigns, permission to photograph and video me and use my picture, silhouette and other reproductions of my physical likeness in published material, on the internet, television, or any other media now or hereafter known, for art, advertising, trade, or any other purpose connected with the marketing efforts of the company.

I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound, willing give my signature.