Share Your Story with NYP

Share your story *:

Do you have any pictures to go with your story? After our team replies, please share any images to accompany your story.

First name*

Last name*

Phone:

Email*

Address 1:

Address 2:

City:

State Province

State/Province

Country

Postal Code:

Please select how you would like to be identified in published materials:

By my full name

By my initials only

I prefer to remain anonymous

Purpose of Consent: By signing this form, you are herby consenting to allow NewYork-Presbyterian and their employees to use, reproduce, or distribute and disclose the information in your testimonial and acknowledge that your testimonial may be distributed to the public for purposes including but not limited to advertising, promotions, and press coverage. I understand that I am not entitled to compensation for use of said testimonial (and/or photographic/videographic likeness). I understand that any written information I provide may be edited. I am voluntarily providing the above mentioned and sharing my story.

Right to Revoke: You have the right to revoke this Release at any time by providing written notice of your revocation. Please understand that revocation of this Release will not affect any action NewYork-Presbyterian, and their employees took in reliance on this Release before receiving your revocation.

Patient/Donor Consent: I hereby authorize NewYork-Presbyterian, and their employees, to use my testimonial (and photographic/videographic likeness) and any information contained herein in its public relations efforts. I understand and approve the disclosure of testimonial information to the media and other individuals and donors that may be involved in the public relations efforts of NewYork-Presbyterian and their employees.

I understand that I am providing on the testimonial information (and/or photographic/videographic likeness) to NewYork-Presbyterian, and their employees, and that my treating healthcare provider will not provide any protected information to the media or to the public, including private health information in my medical records, the confidentiality of which are 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 NewYork-Presbyterian and their employees from any and all claims for damages of any kind based on the use of my testimonial or information in the testimonial (and photographic/videographic likeness).

By signing below, 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 sign this Consent to Release my Patient Testimonial (and/or photographic/videographic likeness.)

*I consent to the Patient Testimonial Release. If my story is selected, I agree to complete and sign an Appearance Release Form, granting NewYork-Presbyterian permission to use my story and images: