Media Guide

MEDIA CONSENT FORM

Please read our Media Consent Form carefully before agreeing to its terms. This form contains information related to the use of your story, photographs and other information you provide to Tennessee Orthopaedic Alliance. By selecting the “I Agree” button below, you acknowledge that you have read, understand and agree to be bound by the terms set forth in this form.

Name of minor patient or person*
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Relationship to minor patient or person*
Phone
Email*
Zip Code
Today's Date
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Type of Consent
- Consent is ongoing
- Consent is for one-time use onlly
Physical Signature in lieu of Electronic Consent
- Paper copy on file at 308 North Peters Road, Suite 225, Knoxville, TN 37922
Phone
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