Free photo release form 36
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UNIVERSITY OF MICHIGAN HOSPITALS & HEALTH CENTERS

MRN (REG #):
PATIENT NAME

Permission to Release Information Including
Photographs, Videos, Electronic or Other Media

Patient

Please identify yourself:

BIRTHDATE:
CSN:

Volunteer

Other (specify): ____________________

Name: ________________________________________________

DOB: ____/____/_________ (mm/dd/yyyy)

Address: ___________________________________

City: __________________________________

State: __________________ Zip: _______________

Phone: ________________________________

Permission to Release:
I give the University of Michigan and agencies acting on its behalf permission to release
information about me, including information about my health. This may include
photographs, videos, electronic or other media involving me.

Yes

No

The items may also be released to any radio, television, internet, print or other media
outlet.

Yes

No

The items may be used by the University including its public relations and marketing un