Patient Hero Agreement

By sharing your ADVENT story you can help others who are interested in knowing more about the patient services provided by ADVENT medical providers.

I hereby consent to be interviewed, recorded, photographed, videotaped or filmed by representatives of ADVENT for purposes of education, publication, display or broadcast (print, web, digital display and all other forms of media).

I agree that such interviews, recordings, articles, quotes, photographs, films, audio or video and/or any reproductions of same in any form, are the property of ADVENT, and I relinquish any present or future claim for reimbursement for said photographic or film reproduction of my likeness or for said testimonials by me. 

I hereby release ADVENT, its affiliates, employees, representatives and agents from any and all claims, demands, costs and liability that may arise from the use of these interviews, recordings, photographs, videotapes or films, and/or any reproductions of same in any form, as described above, arising out of being interviewed, recorded, photographed, videotaped or filmed.

I am not required to sign this authorization. ADVENT does not condition treatment, payment, benefit eligibility or enrollment activities on the signing of this form. I can request a copy of this authorization be mailed to me. If I decide to sign this form, I have the right to request that photographing, audio/video recording or filming cease at any time.

I understand that I may revoke or withdraw this permission at any time to prohibit future use of my information. To do so, I must send written notice to the ADVENT Marketing Department, 10001 W. Innovation Drive, Suite 200, Milwaukee, WI 53222 or to marketing@adventknows.com. I understand that ADVENT, as well as other persons or entities will retain copies of any such printed or electronic versions and shall retain these versions forever and that any revocation of this authorization will only extend to the versions of the information within ADVENT's control that have not been previously published. If not revoked/withdrawn by me, this authorization will not expire.