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Testimonial Consent

Please help us share your story on how our team kept you active!

Your Testimonial/Patient Story may be used by: Dr. Answorth Allen and Hospital for Special Surgery, (“HSS Brands”) in marketing, fundraising and other activities. If you are interested in letting HSS Brands share your Testimonial/Patient Story with the public, please fill out the options below that you prefer.

I have provided a personal quote as my Testimonial and/or participated in an interview for a Patient Story for HSS Brands.

I give HSS Brands permission to share my Testimonial / Patient Story through photos and/or video.

I give HSS Brands permission to use and disclose articles about me when relevant to HSS Brands, including but not limited to articles posted on the Internet.

I give HSS Brands permission to use and disclose any social media that I post that specifically names HSS Brands, including but not limited to photographs, videos, and other electronic media. HSS Brands may pull this information from any of my social media accounts.

Select the Associated Personal Social Media Accounts

Facebook

Twitter

Instagram

YouTube

Other

Authorization and Release of Information

By signing where indicated below, I authorize HSS Brands to use and disclose my Testimonial/Patient Story for the purposes described above. HSS Brands may also include my name, brief biographical information and information about my care and treatment related to HSS Brands with my Testimonial/Patient Story (this information and the /Patient Story collectively referred to as the “Personal Information”).

I authorize HSS Brands to copy, exhibit, publish or distribute my Personal Information on printed publications, multimedia presentations and/or HSS Brands’ websites.

I hereby waive any right to inspect the finished product, including written copy, in which my Personal Information or my likeness appears. I further waive any right to royalties or other compensation arising from or related to the use of my Personal Information.

I hereby hold harmless and release HSS Brands from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators, or other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

This authorization is valid for so long as HSS Brands use Testimonials/Patient Stories in publicity campaigns.

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Timestamp

Audit

December 22, 2021 3:05 pm EDT

Testimonial Consent Uploaded by Answorth Allen - [email protected] IP 47.187.161.52

December 22, 2021 3:15 pm EDT

Jason D'Amelio - [email protected] added by Answorth Allen - [email protected] as a CC'd Recipient Ip: 64.17.23.42

January 7, 2022 11:53 am EDT

Jason D'Amelio - [email protected] added by Answorth Allen - [email protected] as a CC'd Recipient Ip: 47.187.161.52

January 7, 2022 11:53 am EDT

Kristin Mapstone - [email protected] added by Answorth Allen - [email protected] as a CC'd Recipient Ip: 47.187.161.52

January 7, 2022 11:53 am EDT

Melinda Hutchenrider - [email protected] added by Answorth Allen - [email protected] as a CC'd Recipient Ip: 47.187.161.52