Photo and Video Consent Form

Montage Health is committed to educating the public about medical treatments and healthcare. One way we do that is through patient (and their caregivers/family) stories and images that are shared through the media or Montage Health’s own publications and web site. By signing this form, you are authorizing us to share information about you as part of these efforts.

I understand that:

• This information will be shared with the public, through Montage Health’s literature, web site, social media platforms (i.e., Facebook, Twitter) and/or commercial media such as newspapers, television, and radio stations and could include photographs, video and/or sound.
• This authorization will not expire unless specifically revoked by me.
• I may refuse to sign this authorization.
• Once the information is shared through hospital publications, web sites, social media and/or commercial media, Montage Health can’t control its further dissemination.
• I may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered in person or by mail. The revocation will be effective once you receive it, but will not be retroactive.
• Send revocation to: Montage Health, Communication and Marketing, PO Box HH, Monterey, CA 93940
• Clicking the "Submit" button on this form acts as my digital signature

Please email feedback@chomp.org for instructions on sending us photos and videos.