PATIENT TESTIMONIAL – CONSENT RELEASE

Purpose of Consent: By agreeing to these terms, you are consenting to Therapeutic Associates Physical Therapy (TAI) the use and disclosure of the information in your testimonial and acknowledgement that the testimonial may be distributed to the public.

I hereby authorize TAI to use my testimonial and any information in the testimonial in its public relations efforts. I understand and approve the disclosure by TAI of testimonial information to the media and other individuals and entities that may be involved in TAI’s public relations efforts. I acknowledge that the media may be interested in my story, and I am willing to participate in media interviews as they arise. I understand that I am providing the testimonial information to TAI and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). I waive the right of prior approval and hereby release TAI from all claims for damages of any kind based on the use of my testimonial or information in the testimonial. By agreeing to these terms, I agree and acknowledge that I have read and understood the above Release and agree to all terms described. I am of legal age and freely agree to this Consent to Release my Patient Testimonial.

Right to Revoke: You have the right to revoke this Release at any time by giving us written notice of your revocation and submitting it to Therapeutic Associates Physical Therapy (listed below). Please understand that revocation of this Release will not affect any action that TAI took in reliance on this Release before receiving your revocation.


PATIENT PHOTO CONSENT RELEASE

Purpose of Consent: By agreeing to these terms, you are consenting to Therapeutic Associates Physical Therapy (TAI) the use of my photo(s)/video(s) on their website or in any public relations efforts that they see fit. This is including, but not limited to their website, advertising, mailers, etc.

I hereby authorize TAI to use my photo(s)/video(s) in its public relations efforts. I understand and approve the disclosure by TAI of photo(s)/video(s) to the media and other individuals and entities that may be involved in TAI’s public relations efforts. I understand that I am providing photo(s)/video(s) to TAI and that my treating healthcare provider will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). I waive the right of prior approval and hereby release TAI from all claims for damages of any kind based on the use of my photo(s)/video(s). By agreeing to these terms, I agree and acknowledge that I have read and understood the above Release and agree to all terms described. I am of legal age and freely agree to this Consent to Release Media.

Right to Revoke: You have the right to revoke this Release at any time by giving us written notice of your revocation and submitting it to Therapeutic Associates Physical Therapy (listed below). Please understand that revocation of this Release will not affect any action TAI took in reliance on this Release before receiving your revocation.


Therapeutic Associates Inc.
Attn: Marketing Department
20829 72nd Ave S, Suite 710
Kent, WA 98032
253-872-6028 (p)
253-872-4935 (f)