AI Smile Simulation Photo Authorization

As part of planning or discussing cosmetic and implant treatment, the practice offers a computer-generated preview of how your smile could look. To create it, a facial photograph of you is transmitted to one or both of two outside technology companies — Google LLC (the Gemini image model service) and OpenAI (the image editing service) — whose artificial-intelligence systems generate the simulated image.

This form is your written authorization, under the federal HIPAA Privacy Rule (45 CFR § 164.508) and California's Confidentiality of Medical Information Act, for the practice and its staff to disclose the photograph described below to those two companies, for the sole purpose of generating a smile simulation for you to review with your treating dentist.

Who is disclosing: this practice and its workforce. Who receives: Google LLC and OpenAI, each acting as the operator of the artificial-intelligence service that processes the photograph. Purpose: to generate a cosmetic smile simulation at your request, for discussion of possible treatment.

This website does not store your photograph — it is transmitted for processing and is not saved by the practice's website or written to its servers.

The receiving companies process the photograph to generate the simulation. Under the service terms the practice uses, each company may retain the photograph and the generated image temporarily for abuse monitoring — Google for up to approximately 55 days and OpenAI for up to approximately 30 days — after which the companies state the data is deleted. Under those same terms, neither company uses your photograph to train its artificial-intelligence models.

Google and OpenAI are not business associates of the practice and have not signed HIPAA business associate agreements for this service. That is exactly why your signed authorization is required before a staff member may submit your photograph. Once the photograph is disclosed to them, it may no longer be protected by the federal HIPAA Privacy Rule, and it could be redisclosed by the recipient.

The image the system produces is a computer-generated illustration for discussion purposes only. It is not a diagnosis, not a treatment plan, and not a guarantee of any result — your actual outcome depends on your anatomy, your treatment, and healing, and may differ from the simulation.

This authorization expires one year from the date you sign it, or upon your written revocation, whichever comes first.

You may revoke this authorization at any time by delivering a written revocation to either office, in person, by mail, or by email. A revocation stops any further use or disclosure from that point on, but cannot undo a disclosure the practice has already made in reliance on this authorization — including a photograph already transmitted for processing.

Signing is entirely voluntary. The practice will not condition your treatment, payment, enrollment, or eligibility for benefits on whether you sign this authorization. If you decline, the only thing that changes is that no smile simulation is generated — your care proceeds exactly the same. You are entitled to a copy of this authorization once you have signed it; the signed PDF this page produces is that copy, and the office will provide another at no charge on request.