Online Patient Form

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body.

Please select Yes or No for each condition

I hereby grant Christian H Pilgrim, DDS permissions to use my likeness in photographs, video recordings or electric images in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of the organization and will not be returned. I hereby irrevocably authrize the organization to edit, alter, copy, exhibit, publish or distribute these iamges for purpose of publicizing the organization's programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electroci copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arrising or related to the use of my image. I hereby hold harmless and release and forever discharge the organiztion from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I am 18 years of age and am competent to contract in my own name, or if I am under age 18, a parent or guardian has signed below. I have read this release before signing below and I fully understand the contents, meaning and impact of this release.