I hereby consent to be photographed while receiving treatment at the hospital. The “term” photograph includes video or still photography, in digital or any other format, and any other means of recording or reproducing images.
I hereby authorize the use of the photograph(s) by, or disclosure of the photograph(s) to:
Pomona Valley Hospital Medical Center 1798 N. Garey Ave Pomona, CA 91767
I hereby authorize the use or disclosure of the photograph(s) for the following uses or purposes (describe permitted uses, e.g., dissemination to hospital staff, physicians, health professionals, and members of the public for educational, treatment, research, scientific, public relations, marketing, news media, and charitable purposes):
I consent to be photographed and authorize the use or disclosure of such photograph(s) in order to assist scientific, treatment, educational, public relations, marketing, news media, and charitable goals, and I hereby waive any right to compensation for such uses by reason of the foregoing authorization. I and my successors or assigns hereby hold the hospital, its employees, my physician(s), and any other person participating in my care and their successors and assigns harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.