PHOTOGRAPH(S)/VIDEOTAPING AND PATIENT INFORMATION RELEASE
By typing your name below and clicking on “Submit”, you acknowledge and hereby release the NCH Healthcare System, Inc., its medical staff, employees, and agents, from any and all responsibility regarding Photograph(s), or Videotape(s), or Patient Information obtained relating to the subject of the Photograph(s) or Videotape(s), which were taken on the date of or before your submission.
It is understood that the Photograph(s)/Videotape(s)/Patient information may be used inside or outside of the hospital for: Education, Medical, Promotional or Outside Publication.
By checking the box below and typing your name into the Signature box, you are confirming that the above statements are true. You agree that by typing your name, you are electronically signing this document.