Unicare Center for Cosmetic & Implant Dentistry
Realease Form for Media Use

I, the undersigned, do hereby consent and agree that Unicare Center for Cosmetic & Implant Dentistry, its employees, or agents have the right to take photographs, videotape, or digital recordings of me beginning today, and ending upon written notice, and to use these in any and all media, now or hereafter known, and exclusively for any purpose. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

I do hereby release to Unicare Center for Cosmetic & Implant Dentistry, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.

I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.

I also understand that Unicare Center for Cosmetic & Implant Dentistry is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement. If under 18, Parent or Guardian signature needed below.