Media and Medical Release Authorization Agreement

I hereby grant to Rebecca Small, M.D., Dr. Rebecca Small, A Medical Corporation, RSMD Ed Inc., and any other corporate entities of Dr. Small, hereby referred to as “RSMD”; the absolute and irrevocable right and unrestricted permission in respect of my testimonials, interviews, videos, statements, likeness, voice, biographical information, photographs and images (verbal, written or recorded) or in which I may be included with others, hereby referred to as “Media”; to use, re-use, publish, re-publish and copyright in her own name or otherwise the same in any form whether altered, in whole or in part, individually or in any and all media now or hereafter known, for the following purposes throughout the world and in perpetuity: publication (all forms including written, electronic, audio, visual, and any other form not specifically listed), advertising, editorial, art, trade, educational, promotional purpose, broadcast, or any purpose whatsoever.

I waive the right to inspect or approve versions of the Media or any finished product, derivative work or use to which the Media may be applied, for any of the purposes listed above.

I hereby consent to the release of my demographic information, medical information and related materials including discussions of my medical information, to RSMD for purposes of publication, broadcast, training and educational purposes.  I understand that I can revoke this authorization at any time by writing to RSMD but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received.  I understand that should I revoke the release of my medical information, the rights and permissions regarding my Media will be not be revoked. I also understand that I am not required to sign this authorization and that my health care or payment for care will not be affected by my refusal; federal privacy regulations will no longer apply to the information disclosed, and that Rebecca Small, M.D. may re-disclose the information; I am entitled to receive a copy of this authorization; a copy of this authorization may be utilized with the same effectiveness as an original. 

I hereby release and discharge RSMD from any and all claims and demands arising out of or in connection with the use of Media.  This includes, but is not limited to, any claims of defamation, libel, invasion of privacy, or infringement of moral rights, rights of publicity or copyright.

This authorization and release shall also inure to the benefit of the heirs, successors in interest, legal representatives, licensees, and assigns of RSMD and any person associated with the aforementioned.

RSMD are not obligated to utilize any of the rights granted in this Agreement.

In the event that any provision in this Agreement or in any other instrument referred to herein shall be held invalid, illegal, unenforceable, or revoked, the validity, legality and enforceability of the remaining provisions hereof or thereof shall not in any way be affected or impaired thereby.

I have read and fully understand this Agreement, and I read/write English fluently.  I am over the age of 18 and competent to sign this release and I have the right to contract in my own name.  I have had ample time to review this document and have had all of my questions answered. This Agreement expresses the complete understanding of the parties.  This release shall be binding upon me and my heirs, spouses and partners, legal representatives, and assigns.