da Vinci Surgery Patient Stories

IMPORTANT NOTICE TO "SHARE YOUR STORY" PARTICIPANTS. Please read this personal consent and release ("Consent") carefully before agreeing to its terms and participating in the "Share Your Story" program ("Program"). This is a legal and binding contract between you and the Intuitive Surgical, Inc., daVinciSurgery.com's sponsor ("Intuitive"). This Consent contains information related to the use and ownership of your story, images and other information you provide to Intuitive and your participation in the Program. By selecting the "I Agree" button below and participating in the Program you acknowledge that you understand and agree to be bound by the terms set forth in this Consent. You may print this Consent by clicking on the link below or may request a written copy from Intuitive at any time. If you do not agree to the terms of this Consent you will not be authorized to participate in the Program.

By signing this Consent, I grant Intuitive Surgical (Intuitive) and its representatives permission to use my story/photo/video for promotional purposes and, if applicable, to disclose my health information.

1. I authorize Intuitive Surgical's publication of my name/my child's name, photo/likeness/video and all or part of my/his/her testimonial/quotes.
2. I authorize this use in various Intuitive Surgical-sponsored literature such as, but not limited to, newsletters, brochures, web pages and videos promoting the company's products and/or services.
3. I authorize Intuitive Surgical's release of this information to media representatives for the purpose of promoting Intuitive Surgical products and/or services.
4. I understand that Intuitive Surgical will not receive any direct payments for the disclosures.
5. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain Intuitive Surgical's products, services, other treatment, or otherwise affect my healthcare eligibility.
6. This authorization will remain in effect until I revoke it by providing written notice to Intuitive.
7. I understand that if I request it, Intuitive will provide me a copy of this authorization.
8. (Where applicable) As a patient, I understand that this use potentially discloses personal health information, as covered in my testimonial
9. I understand that I may revoke this authorization at any time by providing written notice as set for in Intuitive Surgical's Privacy Policy. However, I understand and agree that if I revoke this authorization, Intuitive Surgical is not responsible for notifying those to whom it has disclosed this information, including media representatives.
10. I understand that once disclosed, my health information may be subject to re-disclosure, at which point it is no longer subject to federal privacy laws.

I represent and warrant that I am legally entitled to enter into this Consent and that I acknowledge that this Consent constitutes a legal, valid and binding obligation.