I, the undersigned, hereby enter into and voluntarily execute this Consent for Patient Testimonial and Release (“Consent”) with Southern Bone and Joint Specialists, P.A. (“SBJ”). I have been informed and understand that SBJ is obtaining patient testimonials and that my name, likeness, image, voice, appearance, oral and written statements, if any, and/or performance may be recorded and made a part of published patient testimonial materials (the “Testimonial”).
1. I hereby grant SBJ, its employees, contractors, agents and representatives the irrevocable right to use my name (or any fictitious name), likeness, image, voice, appearance, oral and/or written statements, and performance as embodied in the Testimonial, or as provided in any medium related to the making of the Testimonial, or as otherwise recorded on or transferred to videotape, film, slides, photographs, audio tapes, DVDs, printed publications, web sites, television or radio broadcasts, social media or any other media or publication now known or later developed. This grant includes, without limitation, the right to use any of my background or demographic information, including diagnosis and treatment, as SBJ deems appropriate for purposes of the Testimonial. This grant also includes, without limitation, the right to edit, digitally enhance or alter, mix or duplicate and to use or re-use the Testimonial in whole or part, as SBJ or its representative may determine. To the extent the Testimonial includes any protected health information (“PHI”), as defined by the Health Insurance Portability and Accountability Act of 1996 (as amended, “HIPAA”), I have executed SBJ’s HIPAA Authorization to further grant SBJ the right to use and disclose such PHI for purposes of creating and publishing the Testimonial. In the event I choose in the future to revoke such HIPAA Authorization, SBJ will cease using any PHI contained in the Testimonial or related materials; provided, however, I understand any future revocation of the HIPAA Authorization will not affect any rights I have granted to SBJ under this Consent with respect to information that does not constitute PHI. SBJ may continue using such information, including, without limitation, de-identified statements or non-identifying images, appearances or likeness, for any lawful purpose. Additionally, I understand that my revocation of the HIPAA Authorization will not affect any right I have granted under this Consent to the extent SBJ has relied upon such grant prior to the revocation.
2. I hereby waive any right to inspect or approve any finished product, including written copy or any other products that may be created in connection therewith. SBJ shall have complete ownership of the Testimonial in which I appear, including copyright interests.
3. I grant SBJ, its employees, contractors, agents and representatives the right to broadcast, exhibit, publish, market, sell and distribute the Testimonial, either in whole or in parts, for any purposes that SBJ, in its sole discretion, may determine, including without limitation advertising and promotion.
4. I confirm that I have the right, authority and capacity and competence to enter into this Consent, and I hereby give all clearances, copyright and otherwise, for use of my name, likeness, image, voice, appearance, oral and/or written statements and performance embodied in the Testimonial. I expressly agree to waive, hold harmless, release and indemnify SBJ and its successors, assigns, affiliates, employees, contractors, agents, representatives and licensees from any and all claims including, without limitation, any and all claims for invasion of privacy, infringement of my right of publicity, defamation (including libel and slander) and any other personal and/or other property rights, arising from, relating to or in any way connected with this Consent. I agree that I shall not now or in the future assert or maintain any such claim against SBJ, its successors, assigns, affiliates, employees, contractors, agents, representatives and licensees. I hereby confirm that I will not be paid for my participation in the Testimonial and I hereby waive any and all rights to any compensation, royalties, or payment of any kind associated with my participation in the Testimonial and with SBJ’s current or future use of the Testimonial.