Dr. Gerilyn Alfe
2704 N. Halsted St.
Chicago, IL 60614
Phone: 773-348-2704
Fax: 773-348-6772
X-Ray Release
Patient’s Information:
Name: _________________________________________ Address: ________________________________
City: ______________________ State: __________ Zip Code: _____________
Phone: ___________________________________ Email: ____________________________________
Date of Birth: _______________________________
I, _________________________________ hereby authorize Chicago Smile Spa to release my dental records and forward them to specialists, dental labs or other persons that may be determined by Dr. Alfe to contribute to my dental care while a patient at Chicago Smile Spa.
I also hereby authorize Chicago Smile Spa to forward my records as to any future request I provide. I will give Chicago Smile Spa written information (via letter, email or fax) as to whom and where to forward my x-rays.
Photo Release
I _______________________________________ do hereby give Dr. Gerilyn M. Alfe DMD d.b.a. Chicago Smile Spa my permission to license the images and to use the images in any media for any purpose (except pornographic or defamatory) which may include, among others, advertising, promotion, marketing, educational and packaging for any product or service. I agree that the images may be combined with other images, text and graphics, and cropped, altered or modified.
Photos to include: Media types to exclude:
Full face – pre-treatment Yes No Advertising __________
Full face – post-treatment Yes No Website __________
Smile – pre-treatment Yes No Office __________
Smile – post-treatment Yes No Promotions __________
TV __________ Educational __________
Additional comments to this release:
____________________________________________________________________________________________________________
If name is to appear, please print how you would like it:
_____________________________________________________________
Patient signature: __________________________________________________________ Date: ___________________________
Witness: _________________________________________________________________ Date: ___________________________
