I (Patient) understand that as a general rule, records of patient identity, diagnosis, evaluation, or treatment are confidential and privileged unless a written consent to their release is submitted. It is my desire to waive confidentiality, ONLY to the extent that my story, audio or video, and/or photographs contains information relating to my identity (including my image and / or likeness), diagnosis, evaluation, or treatment.
This consent allows the use, publication, broadcast, telecast, social media sharing, distribution and circulation of my name photograph, image, and /or likeness for the purpose expressed above and no special favors have been promised to me for agreeing to consent. I may withdrawal this consent at any time, and such withdrawal will not in any way affect my treatment. I understand a withdrawal of consent must be made in writing, and that withdrawal of consent does not affect any information disclosed prior to the written notice of withdrawal. I understand further, that in some cases my facial features may be visible and/ or recognizable. I (or the legal guardian, or parent signing on my behalf) am over 18 years or older, and mentally competent.
I hereby release, indemnify and hold harmless University Health, its staff and employees from any and all claims or causes of action that I may have, of any nature whatsoever, which may in any manner result from the use of the story, photo, video or audio submissions.
