WP E-Signature by Approve Me - Sign Documents Using WordPress -

Informed Consent To Photograph

I due hereby give consent for Dr. Won-Woo Park, and OoLi Orthodontics - Tempe & OoLi Orthodontics – Phoenix to take and/or display photograph(s) of the face and teeth/smile of . The photograph will be used for educational and/or advertising purposes by OoLi Orthodontics - Tempe & OoLi Orthodontics – Phoenix and may be displayed within the office and/or on the office’s webpage, www.ooliortho.com. Dr. Won-Woo Park, and OoLi Orthodontics - Tempe & OoLi Orthodontics – Phoenix team members will protect the patient’s personal data, such as name, age, and date of birth from being displayed.

Print Name (Legal Guardian/Self):

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

June 30, 2020 5:47 am MST

Informed Consent To Photograph Uploaded by Won-Woo Park - forms@ooliortho.com IP 70.163.243.141

April 2, 2023 5:39 pm MST

OoLi Team - drpark@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

April 2, 2023 5:39 pm MST

MJ Cindy Kim - cindy@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141