Patient Story Terms and Conditions

Consent to Photograph and Publish

I authorize Northfield Hospital to photograph or permit other persons to photograph ________________________________________ while under the care of the hospital.  I agree that the hospital may use and permit other persons to use the negatives, prints, videotape or films prepared from such photographs for dissemination in any manner to members of the public for the following purposes: (check all that apply)

                        ________________    Educational

                        ________________    Treatment

                        ________________    Research

                        ________________    Scientific

                        ________________    Public Relations

                        ________________    Advertisement

                        ________________    Promotional and/or fund raising

                        ________________    Other: _________________________________________

Such use is subject to the following limitations:

______________________________________________________________________________

I understand that I have the right to request cessation of recording or filming at any time, and that I have the right to rescind this consent for use up until a reasonable time before the recording or film is used.  I waive any right to compensation for these uses, and I and my successors hold the hospital and its successors harmless form and against any claim for injury or compensation resulting from the activities authorized by this consent.

The term “photograph” as used in this consent shall mean motion picture or still photography in any format, as well as videotape, and any other mechanical or digital means of recording and reproducing images.

Date: _________________________________________________  Time: __________________

Signature: _____________________________________________ Phone Number: __________

Printed Name: __________________________________________________________________

Street Address: _________________________________________________________________

City, State and Zip Code: _________________________________________________________

Signature of Witness: ____________________________________________________________