This authorization does not expire and continues unless revoked. I understand that I may stop the photography, filming, audio, video, or other recording at any time during the recording process. If I change my mind about the use of disclosure, I may revoke or withdraw this authorization at any time unless the use or disclosure process has already occurred. I may withdraw this authorization by contacting:
I further understand that this consent and authorization is optional and I am not required to sign this for medical treatment or payment. I know that I am not entitled to any compensation as a result of any use of information and photographic, film, audio, or video material. I understand I will disclose my information to the affiliated representatives as I choose and may be identified in any use of the above materials.
I hold Alfi Oral, Dental Implant & Facial Surgery and its employees, affiliates, and representatives harmless from any and all liability, claims, and damages arising from this interview and any associated audio, video, or other print or recording used or disclosed as a result. A scan, fax, or photocopy of this form is as valid as the original. By signing below, I acknowledge that I have read and understand the terms of this authorization and knowingly and voluntarily authorize Alfi Oral, Dental Implant & Facial Surgery to use and disclose my protected health information as described above.