Consent to Photograph/Video/Publish

Consent to Photograph/Video/Publish
I give Aspirus Health and its affiliates permission to utilize:*

Photographs of me and/or my children and/or my propertyVideo recordings of me and/or my children and/or my propertyAudio recordings of me and/or my childrenStatements made by me and/or my children
Aspirus Health and its affiliates have my permission to use the above for:*

Aspirus Health publications or communicationsAspirus Health public websiteAspirus Health Social Media (Facebook, YouTube, etc.)Aspirus Health advertising activitiesDepictions of before/after results following a procedureExternal, or third-party publications and/or news agenciesPatient education about surgical outcomes (i.e. patient consultations)Patient education materials or visual displays in the officePublic education, such as lectures to a non-medical audience or non-medical publications and mediaSharing of results, details or approach related to a particular procedure for use by certifying board organizations (i.e. American Board of Plastic Surgery, American Board of Family Medicine)Academic lectures and medical publications
Description (give as much detail as possible):
Use restriction (indicate if applicable):
This consent is irrevocable unless revoked by mutual agreement between the subject and Aspirus Health. I have read and understand this irrevocable release.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name of Person Giving Consent:*

First NameLast Name
Signature:

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Name Parent/Guardian (if minor):

First NameLast Name
Signature of Parent/Guardian

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Date Signed*

MonthDayYear
Name of Aspirus Health Witness

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Signature of Aspirus Witness

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