Your Life Story

This form is to be used to obtain authorization from a patient to release to the public (in response to media inquiries and/or in news releases and reports, publications, marketing materials and/or the web site) photograph(s) and/or information that is related to his/her care, condition and treatment as a patient of Penn Medicine Princeton Health.

I hereby authorize and permit Penn Medicine Princeton Health to take, obtain and make use of photography and publicity of myself and to release information regarding my health, status, care, condition and treatment as a patient of Penn Medicine Princeton Health.

• I understand that such photography, interviews and information may be used for inclusion in media reports, Princeton Health publicity materials (advertisements, billboards and publications) and the Princeton Health web site (www.princetonhcs.org) and other publicity vehicles that have been discussed with me prior to their publication.
• I understand that media reports and Princeton Health publicity materials are widely distributed and made available throughout the Greater Central New Jersey region.
• I understand that no compensation will be provided to me for this release.
• I understand that I have the right to request cessation of filming or recording after my authorization has been given.
• I understand that this authorization may be revoked by writing to Penn Medicine Princeton Health, Marketing & Public Affairs Department, One Plainsboro Road, Plainsboro, NJ 08536.
• I understand that upon revocation of this authorization, Penn Medicine Princeton Health will make reasonable efforts to discontinue the release of this information/photograph whenever possible except where materials are in the process of or have been printed, displayed and/or disseminated to the public.