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We love to hear our patients’ success stories. How has your life improved through your experience with us? Are you moving better and feeling better? Do you have a therapist you want to applaud? Share your experience with us, and we might include your story in one of our upcoming emails or social media posts.

Physician's Name*
Clinic Location*
Tell us about your experience*
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Zip*
Email*
Consent*
Consent, Authorization, Indemnity and Release (“Consent”)
Photographs, Video, Audio and Statements

I hereby grant to Upstream Rehabilitation and its affiliated companies (collectively “Upstream”) permission to record audio, photographs, videos and statements of me (or my minor child) (the “Recordings”). I grant and assign to Upstream full legal title and exclusive copyrights to the Recordings and to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of any Recordings indefinitely for the purpose of marketing or advertising Upstream. I acknowledge that I am transferring all ownership rights to Upstream to the Recordings for the purpose of marketing or advertising.

Authorization to Disclose

I authorize Upstream to use and disclose the Recordings to other Upstream patients, potential patients, customers, employees, agents, contractors, investors, potential investors or the general public in any media now known or later developed, including, but not limited to, publications, newspapers, posters, brochures, magazines, other print media, video presentations, radio transmissions, news releases, billboards, signs, social media, websites, television advertisements, electronic media (including the internet), theatrical media, and electronic and paper mailings, for purposes of marketing or advertising Upstream. I understand that after any Recording is disclosed, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign this authorization will not affect my ability to obtain treatment; my ability to receive payment; or my eligibility for benefits, unless allowed by law. This authorization will be valid for fifty years.

I understand that I have the right to revoke this authorization to disclose the Recordings at any time. I understand if I revoke this authorization to disclose the Recordings at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to Upstream. Notwithstanding the foregoing, I understand that the revocation will not apply to information that has already been disclosed and that it will not revoke my grant and assignment of legal title and exclusive copyrights in the Recordings to Upstream.

Waiver, Indemnity and Release

I hereby waive any right to inspect or approve the use of the Recordings at any time. I also waive any right to royalties or other compensation arising from or related to the use of the Recordings. I hereby agree to release, indemnify, defend and hold harmless Upstream for any damages, attorney fees, costs, fines, penalties, claims, or liability arising from or related to the use of the Recordings. I hereby represent and warrant that I am competent to and have the legal authority to execute this Consent.
I confirm that I have read and understand the above, had an opportunity to ask questions, and agree to all of the foregoing.
I also agree to allow a representative to contact me for additional info about my story.
TO BE COMPLETED BY PARENT/GUARDIAN OF MINOR PATIENT
I hereby represent that I am the parent and/or legal guardian of the minor child listed above, and I acknowledge that I have read and understand the above information, have had an opportunity to ask questions, and hereby agree to the foregoing on behalf of my minor child.
Parent/Guardian's Name
First Last
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