Photo, Video, and Image Release Form

(Minors)

Ihereby authorize D4C Dental Brands, Inc. (“D4C”), those entities/practices that D4C supports, those for whom D4C is acting, D4C’s legal representatives and assigns, and those acting with its authority and permission touse, reuse, publish, and republish the likeness of ______(“Minor”) in any and all of its publications including, without limitation, videos, photographic portraits or pictures of Minor or in which Minor may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations from time to time, in conjunction with Minor's own or a fictitious name, or reproductions of such photographs in color or otherwise, made through any medium, and in any and all media now or hereafter known, including the internet, for art, advertising, trade, printed materials, ordigital/electronic formats).

I also consent to the use of any published matter in conjunction with such videos/photographs. I specifically consent to the digital compositing or distortion of the portraits or pictures, including without restriction any changes or alterations as to color, size, shape, perspective, context, foreground or background.

I understand and agree that any photographs or videos using Minor’s likeness become property of D4C Dental Brands, Inc. and those entities/practices that D4C supports and will not be returned.

I hereby authorize D4C Dental Brands, Inc. on behalf of any of the entities/practices it supports permission to edit, alter, copy, exhibit, publish, or distribute Minor’s likenessfor the purpose of publicizing or any related, lawful purpose.

I waive the right to inspect and approve the final product, including, written or electronic copy, wherein Minor’s likeness appears. Further, I waive any right to royalties or other compensation related or arising to the use of Minor’s likeness.

I hereby hold harmless and release and forever discharge D4C Dental Brands, Inc.,those entities/practices that D4C supports, those for whom D4C is acting, D4C’s legal representatives and assigns, and those acting with D4C’s authority and permission from all claims, demands, causes of action which I, and/or Minor, or either or both of our representatives, executors, administrators or any other persons acting on either or both of ourbehalves or on behalf of either or both of our estates have or may have by reason of this authorization, including, without limitation, any liability by virtue of any reason in connection with the making and use of such videos or photographs, including blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said video(s) or picture(s) or in any subsequent processing thereof, as well as any publication of them, including without limitation any claims for libel or violation of any right of publicity or privacy.

I understand that I may refuse to sign this Authorization and that Minor’sdental/orthodontic treatmentwill not be conditioned upon whether or not I sign this Authorization.

I hereby warrant that I am a legal competent adult and a parent or legally appointed guardian of Minor, and that I have every right to contract for Minor in the above regard. I state further that I have read the above authorization, release, and agreement, prior to its execution, and that I am fully familiar with the contents, meaning, and impact of this release. This release shall be binding upon Minor and me, and our respective heirs, legal representatives, and assigns.

X / FATHER, MOTHER OR LEGAL GUARDIAN SIGNATURE
PRINTED NAME OF FATHER, MOTHER OR LEGAL GUARDIAN
MINOR'S NAME
MINOR'S DATE OF BIRTH
ADDRESS (Line 1)
ADDRESS (Line 2)
TODAY'S DATE
X / WITNESS