I consent to University of Minnesota Physicians contacting me for an interview, writing or editing my story, accepting my photograph/video and publishing a version of the story and photograph in print, broadcast and digital advertising; website and social media; and public relations materials.

I know that information I submit or provide may be used in many ways. This includes fund-raising, marketing, education and other purposes. I will not be informed when it is used. I will not be asked to approve usage, even if a fee is charged for admission or film rental.

I know that any photos or films submitted to or taken on behalf of University of Minnesota Physicians are the property of University of Minnesota Physicians. They are not being taken or submitted for treatment purposes and therefore may not become a part of my medical records. Photographs/videos I submit will not be returned. I can refuse to sign this consent and doing so will not affect my care or payment for my care. I can change my mind after signing this consent by writing to University of Minnesota Physicians at the address below. This will not apply to information already released, and University of Minnesota Physicians cannot prevent a third party from seeing information after it is released.

UMPhysicians Marketing and Communications Department
720 Washington Ave. SE
Suite 200
Mpls., MN 55414

By submitting this form, I am consenting to the above through an electronic signature