Release Form

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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