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Patient information · CID-ADM-04 · v1.0

Photography and Media Release

Optional permission to use your clinical photographs, video, or testimonial outside your dental record. Declining changes nothing about your care.

About 6 minutesRead, sign and download from your own device

Completion

0%

0 of 17 required items

  • Patient details
  • Patient-specific fields
  • Acknowledgments
  • Electronic signature

Before you sign

Review this document before your appointment when possible. Your treating dentist must still explain the patient-specific treatment, benefits, material risks, alternatives—including no treatment—and answer your questions. Do not sign after receiving sedating medication.

1. Who this form is for

Fields marked * are required for a signed PDF.

Treating dentist

Dr. Jain & Dr. Gupta

2. What you are agreeing to

What this form is, and what it is not

Clinical photographs and scans are a routine part of diagnosis, planning, and your dental record, and are taken whether or not you sign this form. This form is separate: it asks whether the practice may also use those images, video, or your written or recorded comments outside your record — for example on its website, in a smile gallery, in printed material, in professional education, or on social media.

This permission is entirely voluntary. Declining, or later withdrawing, has no effect on your treatment, your fees, or your relationship with the practice.

What you are agreeing to if you sign

  • The practice may use the images, video, or comments you approve for the purposes you select below, without payment to you.
  • Images may be cropped, color-corrected, or resized, but clinical results will not be digitally altered to change the appearance of the outcome shown.
  • Any published before-and-after image will state the procedures performed, and will carry a statement that results vary between patients.
  • You may ask the practice to stop using the material at any time. The practice will remove it from material it controls within a reasonable period, but cannot retrieve copies already printed, shared, reposted, or cached by third parties or search engines.

What you should consider before signing

  • Material published on a public website or social media can be copied, screenshotted, or indexed by others and may remain visible after removal from the original location.
  • Images that include your full face, eyes, or distinguishing features may make you identifiable even without your name.
  • You may grant permission for some uses and not others, and you may allow use of your images while declining use of your name.

3. Your case, in your words

May the practice publish a written or recorded comment from you about your care?

4. Confirm, then sign

Patient or authorized representative signature *

Sign inside the box using a mouse, stylus, or finger.

Where this form goes

Nothing you type here is uploaded — the signed PDF is built in your browser. Download the signed PDF saves it to your device and sends nothing. Bring it to your appointment or hand it to the front desk, and staff will place it in your dental record.

Who is responsible for this document

Responsible clinicians

  • Dr. Sambhav (Sam) Jain, DMD, MS

    Lead Implant Dentist & Founder · CA Dental License #50472

  • Dr. Arpana Gupta, DDS, MDS

    Implant Dentist · CA Dental License #50467

Arpana Gupta, DDS and Sambhav Jain, DDS, Inc., practicing as Center for Implant Dentistry.

Where to reach us

  • Fremont

    3381 Walnut Ave, Fremont, CA 94538
    Phone (510) 574-0496 · Fax (510) 574-0499

  • San Francisco

    4318 Geary Blvd, Suite 201, San Francisco, CA 94118
    Phone (415) 696-2922 · Fax (510) 574-0499

Questions about a form? info@bayareaimplantdentistry.com — that address is for questions about a form, not for sending one. A completed form holds health details that should never travel through ordinary email: download the signed PDF and bring it to your appointment, or hand it to the front desk.

What happens to what you type

While you type, nothing is sent and no draft, analytics, or advertising script records your answers. Download builds the PDF in your browser, saves it to your device, and sends nothing — this website never transmits your completed form. Hand it to our staff at your visit so they can place it in your record. Once accepted there, it becomes part of your dental record and is protected under California’s Confidentiality of Medical Information Act (Civil Code § 56) and, where it applies, HIPAA. You can read how we handle records in our health information privacy notice.

Controlled document CID-ADM-04 · v1.0 · Effective 31 Jul 2026 · Next clinical review 31 Jul 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS