Patient Testimonial and/or Photograph Release Consent

Purpose of Consent: By signing this form, you are hereby consenting to allow Fort Wayne Orthopedics, LLC to use and disclose the information in your testimonial and/or your photograph. You acknowledge that your testimonial and/or photograph may be distributed to the public.

Right to Revoke: You have the right to revoke this Release at any time by providing written notice of your revocation to Fort Wayne Orthopedics, LLC- Director of Marketing. You acknowledge that revocation of this Release will not affect any action Fort Wayne Orthopedics, LLC took in reliance on this Release before receiving your revocation.

Consent to Release

I hereby authorize Fort Wayne Orthopedics, LLC and staff to use my testimonial and/or photograph and any information contained herein in its public relations efforts. I understand and approve the disclosure of testimonial information and/or photograph to the media and other individuals and entities that may be involved in the public relations efforts of Fort Wayne Orthopedics, LLC.

I understand that I am providing the testimonial information and/or photograph to Fort Wayne Orthopedics, LLC and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information from my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).

I waive the right of prior approval and hereby release Fort Wayne Orthopedics, LLC from any and all claims for damages of any kind based on the use of the information in the testimonial and /or photograph. By signing below I agree and acknowledge that I have read and understood the above Release and agree to all terms described. I am of legal age and freely sign this Consent to Release my Patient Testimonial and/or Photograph.