I hereby grant to Saint Luke’s Health System and its subsidiaries and affiliates (“you”) my permission to record, film, interview and/or photograph me or my dependent, and use my name, image and likeness and other personal characteristics for the following use(s) (check all that apply):
This consent relates to any treatment, surgery, or procedures performed upon me during my visits at Saint Luke’s Health System. I agree that I will not assert or maintain against you, your successors, assigns and licensees, and the employees, officers, directors, and agents of each of them, any claim, action, suit or demand of any kind or nature whatsoever, including but not limited to those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any reason in connection with your authorized use of my story, medical history, and/or patient information.
I represent and warrant that I have full right, power and authority to grant the rights described in this release.
Saint Luke's is committed to improving your experience. If you have questions, please call Saint Luke's Concierge at 816-932-5100, Monday–Friday, 7 a.m.–5 p.m. In case of emergency please call 911.