Release | DOVE Transplant

Release Form

Your Signature

I hereby authorize DOVE Transplant to use and disclose my Private Health Information (PHI) obtained through interviews, photographs, written communications to the general public for the following purposes:

Print and online distribution of recipient and donor campaigns, flyers, updates (DOVE Social Media sites, print publications, email publications and communications, brochures, website usage)
Broadcast, print and online news media
Educational materials, videos or presentations
Fundraising communications.

I give permission to DOVE to disclose my PHI obtained through interviews, photographs, written communications for the above reasons.

I would like to specifically limit any use or disclosure of the above
(describe here):

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Donor Outreach for Veterans, Corp. DOVE

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I would like to specifically limit any use or disclosure of the above
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