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Media Consent

Media Consent to Photograph, Interview and Publish Information, Statements and/or Images.

I give my consent to Valley Vein Center to photograph or permit other persons to photograph, record, conduct media interviews and/or publish information, statements or images obtained while under the care or on the premises of Valley Vein Center and affiliated properties.

I agree that the photographs and/or radio or television broadcast recordings and/or images may be used in publications or in broadcast formats. I agree that the Valley Vein Center may use and permit other persons to use the negatives or prints prepared from such photographs for such purposes and in such manner as its representatives deem appropriate. I understand and agree that the photographs, recording and/or publication may reveal my identity. I agree that the photographs may be used for any purpose, including, but not limited to, dissemination to hospital staff, physicians, health care professionals and members of the public for education, treatment, research, scientific, marketing, public relations, promotional and charitable purposes, and that such dissemination may be accomplished in any manner, and that such use is subject only to the following limitations:

I consent to the taking and use of photographs, recordings and interviews of me, and to the publication of such photographs, recordings, and interviews, and to the publication of information, statements or images of or about me.

By approving this authorization and consent form, I hereby waive any right to compensation for such uses, and I and my successors or assigns hereby hold Valley Vein Center, administrators, directors, officers, employees or agents and related entities harmless from and against any claim for any injury, and any compensation, resulting from the activities authorized by me in this consent form.

The term “photograph” as used in the foregoing agreement, shall mean motion picture, digital imaging or still photography in any format, as well as videotape, video disc and any other mechanical means of recording and reproducing images.

I hereby waive my right under relevant state laws to patient confidentiality with respect to the taking or publishing of any photograph, recording, interview, statement or image of me, as authorized in this consent form, with the exception of those limitations specifically identified by me in this consent form. I understand that I have the right to revoke this waiver by notifying Valley Vein Center in writing.

This authorization is effective for three (3) years from the date I submit the authorization, unless I otherwise indicate or revoke it prior to that time by notifying Valley Vein Center in writing.

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