I, authorize Paley Orthopedic & Spine Institute and its and its affiliates (collectively,
“Hospital) to use and publish in any public manner Hospital deems reasonably appropriate, my name, voice, photograph,
likeness, quotes, stories and/or any other information, statements or images (collectively, “Personal Materials”):
1. For any commercial or non-commercial purposes, including but not limited to, marketing, advertising,
fundraising, development, public relations, media relations, charitable, educational and scientific purposes;
2. In the form of print, audio, visual and social media, including but not limited to, articles, blogs, websites,
brochures, pamphlets, newsletters, fliers, posters, advertisements, newspapers, film, live or taped television
transmission, videotape, radio broadcast, and internet publication.
The term “photograph” as used in this Authorization and Consent means motion picture, still photography or visual
recording of any kind and in any format such as slides, negatives, prints, videotape, video disc, and any other means of
recording and reproducing images, including composite or modified representations.
By submitting this Authorization and Consent, I understand that once my information is published and in the public
domain, my information may be re-disclosed and will not be protected under the Health Insurance Portability and
Accountability Act of 1996, as amended. I hereby waive any right to compensation for such uses, and I and my
successors or assigns hereby hold Hospital and its administrators, directors, officers, medical personnel, other
employees or agents and their successors and assigns harmless from and against any claim for any injury, and any
compensation, resulting from the activities authorized by me...
This Authorization and Consent remains valid for ten (10) years from the date of signature unless revoked in writing. II
understand that that any such revocation will not affect the commencement, continuation or quality of my treatment
at Paley Orthopedic & Spine Institute. Any revocation will not have any effect on any action taken in reliance on this
Authorization and Consent before Hospital received my written notice of revocation..
By submitting this form, I acknowledge that I have read and understood the above and agree to the terms of this
Authorization and Consent Form.