Zeifman Orthodontics on occasion takes photos and videos of patients to be used in the office, on the Zeifman Orthodontics website, Facebook, newsletters, print and related publications. This list is not inclusive but serves to demonstrate situations in which patients may be photographed or filmed.

  I give permission to Zeifman Orthodontics to display my photo(s) or video(s) in association with Zeifman Orthodontics events, functions, or publications.

 I give permission to Zeifman Orthodontics to correspond via e-mail or text regarding appointments and patient information. 

 I request that Zeifman Orthodontics does NOT correspond with me via e-mail or text regarding appointments and patient information.

Signature of PARENT or legal guardian (if under 18)

 Signature of Patient (if over 18)

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