Consent for Photography, Video/Television, Audio/Sound Recordings and Interviews

Patient Information

Patient First Name:

Patient Last Name:

Patient Date of Birth

Parent/Legal Guardian Name:

Name of the event or promotional purpose:

Please list the names of everyone that will be attending besides yourself:

Enter full name followed by DOB (MM/DD/YYYY) of each minor that will be attending.

Consents and Disclosures

I give consent

Consent for Photography, Video/Television, Audio/Sound Recordings and Interviews:

I hereby give my consent and authorization to Nicklaus Children’s Health System, Nicklaus Children’s Hospital, and Nicklaus Children’s Hospital Foundation, including its physicians, authorized technicians, employees, and authorized agents (collectively “Nicklaus Children’s”) to photograph, film, create digital images, video, interview, create sound recordings, creative works, or otherwise create media content (“Content”) of me/my child related to the event identified above or treatment of my/my child’s medical condition(s), including any operative or special procedures performed, for the purposes indicated in this consent.

I understand that such media content may include my/my child’s face, image, likeness, voice, name, age, any and all information regarding my/my child’s medical condition(s), treatment, status, prognosis, and other protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA) as amended, and other federal or state privacy laws. I hereby consent to and specifically authorize Nicklaus Children’s to disclose and use such Content as indicated:

I give consent

Medical Education:

The Content may be used by NCHS for purposes of medical education, study and training, including possible publication in scientific or professional journals, articles, or other publications. Disclosures may be made to physicians, residents, fellows, medical students, affiliated academic and educational institutions, local and national medical, scientific, and educational entities and groups, and any source for medical education purposes.

I give consent

Marketing or Media Purposes:

The Content may be used by NCHS for internal and external marketing, public relations, communications, and promotional purposes. Disclosures may be made to national and local reporters, television programs, news agencies, radio stations, internet, and social marketing or media sites.

I give consent

Hold Harmless Agreement:

I understand the Content and any and all reproductions of the Content obtained or created by NCHS remains the property of that NCHS entity. Any Content created by external media remains the property of that external media, unless otherwise agreed. All Content disclosed in reliance on this consent may be re-disclosed to other parties and may no longer be protected by state or federal privacy laws.

I hereby agree to hold NCHS free and harmless from any and all liability arising out of the use and/or release of Content.

I understand I may refuse to sign this consent, and that my refusal to sign will not affect in any way my or my child’s ability to obtain treatment at NCHS or any of its sites. I understand that NCHS is not requiring me to sign this consent as a condition to receiving treatment, making payments on any bills, or gaining enrollment or eligibility in any health insurance plan, unless the Federal Privacy Regulations allow it. I realize that I/my child will not be compensated in any way by NCHS for providing, participating in, or consenting to use of Content.

I understand that I may revoke this authorization at any time, provided I do so in writing and send such writing to NCHS, attention: Marketing Department. I understand that any Content disclosed between the effective date of this consent and the date of my revocation may still be used by NCHS. This consent shall remain in full force and effect as of the effective date below, unless and until a written revocation is received by NCHS.

Contact Information

Email address:

Phone number:

Address:

Enter full name of Parent, Guardian or Patient (over 18 years of age) filling out this form:

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