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MEDIA CONSENT FORM:
I, hereby give, assign and grant to NCDR, LLC and all practices operating under a practice management agreement with NCDR, LLC and doing business as Kool Smiles (collectively, “Kool Smiles”), the right and permission to use and/or publish my statement, photographs, voice recording, videotape and/or digital images (the “Content”) for media relations use in addition to promotion or education materials that may include but not limited to print publications or materials, electronic publication or presentation and web sites. I agree that my name and identity may be revealed in descriptive text or commentary in connection with the Content.  All negatives, positives, prints, digital reproductions and video/audio tape shall be the property of Kool Smiles.
I acknowledge that I will not receive, nor will I be entitled to receive, any compensation or consideration for the use, sale, publication or reproduction of the Content, now or at any time in the future.  In addition, I shall have no claims against Kool Smiles (including, without limitation, claims based upon invasion of privacy, defamation, or right of publicity) arising out of any use or alteration of the Content.  I further release and hold harmless Kool Smiles, its agents, employees, nominees, assigns, and designees, from any liability arising out of the use, sale, publication or reproduction of the Content.


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