Share Your Story

By submitting the form below you agree that Midwest Orthopaedics at Rush may use and permit other persons to use the consented materials for purposes including, but not limited to, dissemination may be accomplished in any manner. Such use is subject only to the following limitations(s) listed below (if any):

I understand that:

1. I may refuse to sign this authorization, and my participation is strictly voluntary. If I do not sign this form, my health care and the payment for my health care will not be affected.
2. I will receive no compensation for my participation.
3. This consent form has an unlimited time frame, and the materials may be retained indefinitely.
4. I have the right to request that my participation end at any time. I understand that I have the right to withdraw my consent at any time, provided that I do so a reasonable time before the materials are used.
5. By signing this form, the personal health care information I relay to an outside source is no longer protected by state and federal privacy laws and may be disclosed by that source.
6. I can obtain a copy of this form after I sign it.

I understand that, in the instance of outside sources (such as the media), Midwest Orthopaedics at Rush is acting only as the intermediary, making it possible for the aforementioned source(s) to contact me. I agree to hold Midwest Orthopaedics at Rush and its members, directors, officers, and employees harmless from any and all liability arising out of the use and/or release of information, interview, photograph/video/film, and subsequent publication or broadcast.