I, {patientName}, hereby give my consent to TRS Care, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising, or other media activities (including the Internet). I grant TRS Care:
- Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
- Permission to use my name and my medical diagnosis; and
- Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.
I, {patientName}, release TRS Care and their respective employees, officers and agents from any and all liability which may arise from the use of such news media stories, promotional materials, written articles, videotape and/or photographs.
I understand that I can revoke this permission at any time in writing and that the use of my photos or other information authorized by this release will immediately cease. I understand that revoking this release does not include any posts already used by the authorization of this release.