Consent and Release to Photograph or Record

I authorize Rush to use, distribute or display any of these images or recordings for medical education and training, internal or external marketing, recruiting, or scientific/medical reporting or publication.

I specifically authorize Rush to take photographs or recordings during the course of medical treatment. I understand that Rush will retain ownership and possession of these images or recordings, but that I will be allowed to view or obtain copies of them, if requested.

I understand that Rush will maintain all images or recordings in a secure manner for the time period required by law or as outlined in the hospital’s medical records retention policy.

I understand that I have the right to request that the photography or recording end.

I understand that I have the right to withdraw my consent at any time, until a reasonable time before the photographs or recordings are used.

I understand that medical care is not dependent upon this consent being signed.

I hereby release Rush and all of its employees or agents from any and all liability which may or could arise from the taking, recording, publication, distribution or other use of these photographs or recordings.

By signing below I state that I am 18 years or older, or that I am otherwise authorized to consent. I have read this entire form or have had its contents explained to me. I have had a chance to questions and all my questions have been answered.