I, on behalf of myself, my heirs and assigns, grant Medtronic, Inc., its subsidiaries, successors, assigns, employees, and agents ("Medtronic"), the right to use my name, my photographic likeness, date of birth, sex, occupation, nationality and health information related to my Medtronic therapy (hereinafter "Personal Data"). I agree to the use and processing of my Personal Data for the purpose of portraying an example of a patient who has been treated with a Medtronic therapy for Medtronic advertising, marketing, medical research, medical education and new product development objectives.
I give Medtronic worldwide permission to reproduce, publish, exhibit, distribute internally and to third parties, use and/or transmit my Personal Data, or any combination or portion of the same by any means, including but not limited to videotape, print image, motion picture, brochures, written documentation, the Internet or other electronic media. Such Personal Data may be transmitted along with audio or print transcripts of statements made by me.
I understand that a copy of this Release will be stored electronically and will be accessible to Medtronic employees and contractors requiring access to the electronic system in order to perform their job-related responsibilities.
I understand that my consent to the use or transmission of my Personal Data is irrevocable.
I am giving this Release in the interest of advancing patient care and education. I understand that I will not receive any payment for the use of my image or for the use or processing of my Personal Data.
By checking the "agree" box, I consent to the information stated above.
