Photo/Video Media Release Form

PROVIDING PERMISSION TO USE YOUR VIDEO/PHOTO The undersigned being the legal owner of, or having the right to permit the taking and use of photographs/videos does grant to CHROME GuidedSMILE, the restorative dentist, and his/her agents or assigns, the full rights to use such photographs and copyright same, in advertising, trade, or for any purpose. a) I also permit the use of any printed material in connection therewith. b) I hereby relinquish any right that I may have to examine or approve the completed product or products or the advertising copy or printed material that may be used in conjunction therewith or the use to which it may be applied. c) I hereby release, discharge and agree to save harmless [photographer] his/her heirs, legal representatives or assigns, and all persons functioning under his/her permission or authority, or those for whom he/she is functioning, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be created in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy. d) I hereby affirm that I am over the age of majority and have the right to contract in my own name. I have read the above authorization, release and agreement, prior to its execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives and assigns.