Publicity Consent Form

I understand the primary purpose/subject of this interview, account of events, video, film, recording, and/or photo is to be shared with the public on greenvillemidwiferycare.com, on other websites owned and operated by Greenville Health System,  and may be shared on public Social Media networks on the internet. In addition, I give permission for Greenville Health System to use this interview, video, film, recording, and/or photo in a reasonable manner consistent with the community efforts and mission of Greenville Health System.

By agreeing this form, I give Greenville Health System my permission to use the interview, video, film, recording, and/or photo for the purposes indicated above without any limitations, including use in newspapers, magazines, Web sites, radio, and television. In the case of an interview, I understand that by signing this form I also give permission for the interviewed physician to discuss my case.

By signing this form, I waive any and all rights, ownership, and interest in publications, photographs, and/or recordings resulting from the use of interviews, videos, films, recordings, and/or photographs.

I understand that I may inspect and/or request a copy of the interview, video, film, recording, and/or photo being made. Prior to publication, I may be provided with a copy of any text that will be used.

I understand that my permission does not entitle me to any payment, treatment, enrollment in a health plan, or eligibility for any benefits.

I also agree not to hold Greenville Health System and/or its agents responsible for any publicity or any effect whatsoever that may result from the use or disclosure of this interview, video, film, recording, and/or photo. I may not claim any invasion of my privacy, any misuse of my likeness, or any other damage to my reputation as a result of my giving my permission for use or disclosure of this interview, video, film, recording, and/or photo. The permission will expire when I withdraw my permission in writing.

I certify that I am giving my permission freely and that I may withdraw my permission at any time before Greenville Health System and/or its agents take action based on my authorization.

I understand that giving my authorization to use the interview, video, film, recording, and/or photo being made is completely voluntary. I understand I may refuse to sign this authorization and that if I refuse, my decision will not affect my ability to receive treatment at Greenville Health System.

I understand I may withdraw my permission to use the interview, video, film, recording, and/or photo being made at any time by giving GHS written notice and that Greenville Health System and/or its agents may continue to use the interview, video, film, recording, and/or photo unless I withdraw my permission in writing.