Participant consent and release form

The undersigned hereby authorizes or ratifies using quotes and testimonials, the taking and use of photographs, film, audiotape and/or videotape during treatment or other procedures including special events hosted by Ochsner Health System; including Ochsner Health System, its subsidiaries and affiliates, including Ochsner Clinic Foundation, a not for profit Louisiana corporation, Ochsner Community Hospital, a not for profit Louisiana corporation, individually and as manager and on behalf of Ochsner Medical Center – Kenner, L.L.C., Ochsner Bayou, L.L.C. d/b/a Ochsner St. Anne General Hospital, East Baton Rouge Medical Center, L.L.C. d/b/a Ochsner Medical Center – Baton Rouge and Ochsner Medical Center-Northshore, L.L.C. and Chabert Operational Management Company, LLC, as manager and on behalf of Leonard S. Chabert Medical Center, and any other subsidiaries and affiliates, for use by these institutions for the purpose of public relations, business development, sales, and internal and external marketing activities, including use by or for news media, and further authorizes the use of the undersigned’s name with said photos, film, print or tape in advertising activities, television commercials or broadcasts, radio ads or broadcasts, onsite vehicles (plasma screens, kiosks, etc.), print ads, annual reports, brochures, web sites, online outlets, outside billboards, business communications, books, scientific or industry papers, internal communications, e-news letters, email marketing, social media platforms or outlets (including but not limited to mobile/smart phones, Facebook, Twitter, YouTube, Flicker, etc, and/or any digital technologies, including those not known today.)