Consent to Photograph and Interview

Consent to Photograph and Interview

Occasionally, hospitals or healthcare providers make and use photographic, video, electronic, audio media or interviews of patients for external and internal use other than the identification, diagnosis, or treatment of the patient (for example, performance improvement, education, commercial filming, television programs, paid advertisement or marketing material).
Facility:

Other MWHC Facility
Facility

Other MWHC facility
Are you interested in providing a patient testimonial?
Service, facility and/or provider
Approximate date of care
Preferred contact
Please include your phone number or email address for a member of the Marketing & Communications department to contact you
Name

First NameLast Name
Child's Name (if applicable)

First NameLast Name
I, First Name* Last Name* consent to have photographic, video, electronic, audio media or interview of myself, my child(ren), or for the person(s) for whom I am responsible conducted on: Date* by Photographer/Interviewer*

I also consent to the use of this media in the following publication, education, paid advertisement or audio-visual program, to include MWHC social media and website. (Type ALL for all media locations.)

*
I consent / decline (choose one) that my first name, the first name of my child(ren) and/or the person(s) for whom I am responsible be shared for the use in the publication, education or audio-visual program listed above.
I consent / decline (choose one) to having friends, family and/or the caregiver interviewed regarding my condition, the condition of my child(ren), and/or the condition of the person(s) for whom I am responsible.
I consent / decline (choose one) to having general information regarding my condition, the condition of my child(ren), and/or person(s) for whom I am responsible released by a Mary Washington Healthcare spokesperson, and if applicable, to law enforcement personnel conducting official investigations.
I hereby release Mary Washington Healthcare, its subsidiaries, its personnel, my friends, family, caregiver and any persons participating in my care, the care of my child(ren) or the care of the person(s) for whom I am responsible from any and all liability that may or could result from the taking or the use of this media, release of general information by a Mary Washington Healthcare spokesperson and release of information to law enforcement personnel.
Note: If the above patient is an unemancipated minor (under the age of 18), the above consent is given on the patient’s behalf by:
Witness signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Should be Empty: