Consent to Photograph, Record, Film or Interview Indicates required field 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): Marketing Marketing purposes which can include any of the below and others determined useful by Saint Luke's Health System: Public news media (print, electronic or broadcast Social Media/website Health Magazine Foundation/Donor Messaging Clinical Clinical purposes which can include any of the purposes listed below and others determined useful by Saint Luke’s Health System: Performance improvement Research Educational 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. Your Name Are you the patient? - Select -YesNo Relationship to patient Patient Name Date of Birth Phone Address Address 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Email Purpose for Consent/Additional Notes Signature (Typed) Electronic submission of this form signifies that I have read and understand the Consent to Photograph, Record, Film and Interview form and that my questions have been answered to my satisfaction.