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  • Media Release Agreement

    I consent that a statement/interview, and/or photograph, and/or illustration, and/or video, and/or audio recording may be taken of me by Madeira Chiropractic Wellness Center, Inc. regarding my personal and medical history, condition(s), and treatment(s) for the purposes of documentation, education, publication, promotion, marketing, or advertising activities, programs, and services. I grant permission for the above-described material(s), which may include Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPPA), to be used by news media, including professional medical or healthcare journals, for publication, and/or broadcast, and/or distribution via other means to the general public, not excluding its use at professional meetings, symposiums, poster sessions or other events. I recognize that the precise manner in which the information and material(s) may be used will be determined solely by Madeira Chiropractic Wellness Center, Inc.
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