KT Dental Centre™ - Consent for the Use of Photographic Images & Audiovisual Recordings

KT Dental Centre

Số 01 Sương Nguyệt Ánh, Phường Bến Thành, Thành phố Hồ Chí Minh, Việt Nam

(028) 555 999 68

Contact

Email: admin@ktdental.com.vn

Web: https://ktdental.com.vn/

1. Patient Information

Participant's Full Name *

Participant's Date of Birth *

Address *

Parent/Guardian's Name (if applicable)

Email *

Level of Consent

Please review the options below and indicate your level of consent for the use of photographs and/or audiovisual recordings. You may choose more than one option.

Internal Use Only

Within the organization, including educational and promotional materials distributed internally, internal presentations, or staff training.

Public Use

On external platforms, including the organisation's website, social media, and printed promotional materials.

No Social Media

Allow public use (e.g., website, brochures) but NOT on social media platforms.

Face Usage Permission

I consent to use of images/recordings where my (or my child's) full face is visible.

Face Covered Use

I consent to use of images/recordings where my (or my child's) face is partially or fully covered (e.g., blurred or cropped).

Optional notes / permitted contexts

3. Duration of Use

Indefinite / until withdrawn Until a specific date Specific period

I consent to the use of these images and recordings for the duration selected above. If "Indefinite" is selected, consent remains until withdrawn in writing.

4. Rights & Ownership

I acknowledge I will not receive compensation and waive any rights to inspect/approve the finished materials or their use.

5. Privacy & Confidentiality

KT Dental Centre™ will not use images/recordings in a way that is defamatory, misleading, or violates my privacy.

6. Withdrawal of Consent

I understand consent can be withdrawn anytime by written notice to KT Dental Centre™. Materials already published or distributed before withdrawal may still be used.

7. Signatures

Participant's Signature

Sign with mouse or touchpad

Date *

Parent/Guardian Signature (if applicable)

Sign with mouse or touchpad

Date *