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Consent to Media Release / Photograph & Publish

Photo Consent & Media Release

  • 1. DEFINITION OF PHOTOGRAPH • The term “photograph” or “photographs” as used in the following provisions of this consent shall mean motion picture or still photography in any format, as well as video tape, video disc, televising and other mechanical means of recording and reproducing images.

    2. CONSENT TO PHOTOGRAPH

    i. The patient/resident identified herein and the undersigned hereby authorize Portneuf Medical Center and the attending physician to photograph or permit other persons to photograph (patient’s/resident’s name as listed below) while under the care of the above-named medical center, for purposes including but not limited to identification, documentation, diagnostic, therapeutic treatment, educational, research, scientific, public relations, charitable objective and/or other medical purposes.

    ii. The patient/resident identified herein and the undersigned agree that the above-named medical center and the attending physician to reproduce any and all photographs taken of the patient/resident while under the care of the above-named medical center.

    iii. The patient/resident identified herein and the undersigned agree to allow the medical center and the attending physician to release information to the media regarding care and treatment.

    3. CONSENT TO PUBLISH

    i. The patient/resident identified herein and the undersigned agree that the above-named medical center and the attending physician may: 1. Use the photographs for circulation to medical center staff, physicians, and other health care professionals for identification, documentation, diagnostic, therapeutic, treatment, research, scientific, educational and other medical purposes. ii. This constitutes a final and conclusive release of the photographs by the patient/resident and/or the undersigned. iii. This also constitutes a final and conclusive release of information for media release.

    4. WAVER OF COMPENSATION The patient/resident identified herein and/or undersigned have signed this consent in order to assist in the purposes named above and hereby waive all right that he/she/they may have to any claim for payment, royalties or compensation in connection with any exhibition of the subject photographs.

    5. HOLD HARMLESS PROVISION The patient/resident identified herein and/or the undersigned and his/her/their successors or assigns hereby release the above-named medical center, its employees and agents, as well as the attending physician from any liability in connection with the use of the photographs and hold the above-named medical center and attending physician and their employees, agents, successors, compensation resulting from the activities authorized by this consent.

    THE PATIENT/RESIDENT IDENTIFIED HEREIN AND/OR UNDERSIGNED CERTIFY THAT HE/SHE/THEY HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT.

  • your typed name will be used as an official signature
  • :
  • This consent valid for this admission only and may be withdrawn by the patient at any time by notice to the center.
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