Media Release Consent Form

I hereby grant full permission to New Hampshire Orthopaedic Center to prepare, use, reproduce, publish, distribute and exhibit my name, picture, portrait, likeness or voice, or any or all of them in connection with the production of a motion picture film, video tape or film recording, soundtrack recording, interactive web or still photography in any manner for educational treatment, scientific publication, information and any other professional purpose deemed necessary. This permission extends to any authorized print or broadcast media organization who may participate in such preparation, use, reproduction, publication or distribution and;

I hereby waive any and all rights of privacy or compensation which I may have in connection with the use of my name, picture, portrait, likeness or voice, or any or all of them, in or in connection with said motion picture film, videotape or film recording, soundtrack recording, interactive web or still photography and any to which the same or any material therein may be put, applied or adapted by New Hampshire Orthopaedic Center and any of its companies.

This consent and waiver will not be made the basis of a future claim of any kind against New Hampshire Orthopaedic Center or any of its companies. I acknowledge that any photograph, motion picture, movie, videotape, or audiotape taken of me will become the property of New Hampshire Orthopaedic Center and the authorized print or broadcast media organization. A copy of any photograph, motion picture, movie, videotape or audiotape of me obtained for purposes or in the course of medical treatment will be contained in my treatment record maintained by New Hampshire Orthopaedic Center.