Consent to Create and/or Use Photos, Recording or Broadcast

I agree that Allina Health or its representatives may use existing images or recording or may create photographs, voice or audio recordings, or broadcasts of images or recordings of me as indicated here: (Check all that apply)

Photograph      Audio Recording    Video Recording    Broadcast

The purpose for which the photograph, recording or broadcast will be created or used is:

(select one from list or if none apply, enter brief description of the project – e.g., marketing, presentations, staff education, patient education, promotional, advertising, quality review)

I understand that:

§  I can ask to stop the photography, recording or broadcast at any time before it starts or while it is happening.

§  If I am a patient, I have the right to cancel this consent before the images, recordings or broadcast are used.

I agree that:

§  All images or recordings and/or copies will be the exclusive property of Allina Health,

§  Allina Health may keep or use the images or recordings now or in the future.

§  Allina Health may use personal information about me in connection with the photograph, recording or broadcast, which may include my name, health information and other personal information that I provide to Allina Health.

§  Allina Health does not owe me any payment for any benefit it receives for the use of my images or voice, including for marketing or publication of the images or recordings.