Media Release Form

In order for us to share your #Back2Active story with the general public, we are requesting your permission to take photos and/or videos, or use the photos/videos you upload below, for use in our various marketing materials, including, but not limited to, our website, newsletters, programs, brochures, social media, or mass media outlets.

Please provide your first & last name *

Please provide your address *

Please provide your phone number *

Which provider did you see? *

At which location were you seen? *

Your #Back2Active Story

Photo/Video Description

Please provide us with a detailed description of the photo or video by answering the following questions:

Where was this photo or video taken?

When was this photo or video taken?

Please share the full names of the people in this photo/video from left to right or in order of appearance.

Upload Photo/Video

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png avi mov mp3 ogg wav.

Waiver *

I do hereby grant to Appalachian Orthopedics all rights to exhibit this work in print, electronic, or other form, publicly or privately, and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. The images, once released, are in the public domain forever and can be manipulated, altered, and transmitted beyond the control of the physician or Appalachian Orthopedics. Nothing requires Appalachian Orthopedics to use my photographs or recordings in any marketing materials.

No Payment *

I understand that there will be no financial or other remuneration for interviewing and/or recording me, either for initial or subsequent transmission, playback, or publication.

Liability *

I release Appalachian Orthopedics for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

Age Verification *

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this release.

Media Release Form

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