Patient Photography/Video Release - Women's Health Specialists

NOTE: This form is NOT required for photos or videos of patients used for the purposes of treatment or diagnosis, where the photo and/or video becomes part of the patient’s medical record and is not used for any other purpose.

Patient Name*

First Last

I authorize the Women's Health Specialists ("WHSFL") to take photographs and/or videos, or to allow third parties to take photographs and/or videos, or to use photographs and/or videos provided by the above named subject, including photographs of their babies delivered by WHSFL, for the following uses:

For Public Relations

On WHSFL internet and intranet sites

In WHSFL publications and brochures

In the public media, such as newspapers, magazines, on the internet, and on television

In presentations, publications, brochures, advertisements, or articles by non-WHSFL agencies or companies, such as other non-profit organizations or for profit companies who provide support to WHSFL

For Medical or Educational Purposes

In professional journals and other publications, including textbooks and electronic publications

In presentations by WHSFL faculty, staff, and employees, including professional and educational conferences or seminars

In WHSFL classrooms and other teaching environments

Information Release*

I consent to the use of my name. I understand that I may be identified by name in printed, internet or broadcast information that might accompany the photo or video image of me.

I do not consent to the use of my name. I understand that, even though my name will not be used, it is possible that someone may recognize me based on the image(s) alone.

Selective Information Release

Check the box below to specify the information WHSFL may share.

I authorize the use of the following information about me, my medical condition, or my treatment:

Specify the information WHSFL may share

I understand that:

I may revoke this Authorization at any time:
- the revocation will not apply to information that has already been released in response to this Authorization.
I may refuse to sign this Authorization:
- WHSFL will not condition my treatment, any payment, enrollment in a health plan, or eligibility for benefits on receiving my signature on this Authorization.

I have been informed and understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected by federal and state privacy laws.

Authorization Exipration

Unless otherwise revoked, this authorization will expire on the following date (mm/dd/yyyy) , event, or condition (if left blank, this authorization will expire one year from the date it is signed).

Upload your photos

Upload any photos that you would like for us to feature.

Drop files here or

Accepted file types: jpg, jpeg, webp, Max. file size: 4 MB, Max. files: 5.

Signature

By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Are you the patient or the authorized representative of the patient?*

I am the patient.

I am the authorized representative of the patient.

Name*

First Last

Today's Date