Home / New patients / Photo permission

Permission to share photos of your smile

This is optional. Saying no, or never filling it out, doesn't change your care, your appointments or what you pay.

Demo form. Nothing here is sent or saved.

Patient's full name

Patient's date of birth

What you're agreeing to

What we'd share: Photos of the patient's teeth and smile taken during care at Cascade Dental, before and after treatment. Choose below whether the face may show.
Who shares it: Cascade Dental, 1200 Glacier View Way, Orting, WA 98360.
Who could see it: Anyone who visits our website or our social media pages, and readers of our printed materials.
Why: Marketing: to show the kind of results our patients get. We are not paid by anyone for these photos.
Until when: Until the date you choose below, or until you take this back, whichever comes first.
Taking it back: You can take this permission back at any time by telling us in writing (a letter, or the contact form on this site). We'll remove the photos from our website and pages within 10 business days. Copies other people already made or saved can't be recalled.
Your care doesn't depend on this: We will not make treatment, payment, enrollment or eligibility depend on whether you sign.
Once it's public: After a photo is shared publicly, it is no longer protected by federal privacy law, and others may copy or share it.

What may show in the photos? Teeth and lips only, no face The full face may show

This permission ends onMost people choose two or three years from today.

Who is signing? I am the patient I am the parent or legal guardian of a patient under 18

Your signature

Draw it Type my name

Signed . You'll get a copy by email.