Testimonial, Video, Photo, Audio Release Consent

By signing this form, you are hereby consenting to allow Avante Medical Center, LLC to use and disclose your testimonial, audio, photos, and/or videos, and you acknowledge that they may be distributed to the public.

You have the right to revoke this Release at any time by providing written notice of your revocation and submitting it to the Contact Person listed below. Please understand that revocation of this release will not affect any action Avante Medical Center, LLC took in reliance on this release before receiving your revocation.

I hereby authorize Avante Medical Center, LLC and staff to use my testimonial, photos, videos, audio, and any information contained herein in its media/public relations efforts. I understand and approve the disclosure of the testimonial, photo, video, audio information to the media and other individuals and entities that may be involved in the media/public relations efforts of Avante Medical Center, LLC.

I understand that I am providing the testimonial, photo, video, or audio information to Avante Medical Center, LLC and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information in 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 Avante Medical Center, LLC from any and all claims for damages of any kind based on the use of my testimonial, picture, video, audio, or information in the testimonial. 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 other media I provided to the doctor.