Montage Health and its subsidiaries (Aspire Health, Community Hospital of the Monterey Peninsula, MoGo Urgent Care, Montage Health Foundation, Montage Medical Group, Montage Orthopedics and Sports Medicine Center, and Montage Wellness Center) are committed to educating the public about medical treatments and healthcare. One way we do that is through patient stories that are shared through the media or our own publications, digital channels, and websites. By signing this form, you are authorizing us to share information about you as part of these efforts.

I understand that:

• This information will be shared with the public through Montage Health’s literature, websites, digital channels, and/or commercial media such as newspapers or television and radio stations and could include photographs, video, and audio
• This authorization will not expire unless specifically revoked by me
• I may refuse to sign this authorization
• Once the information is shared through the healthcare system’s publications, websites, digital channels, and/or commercial media, Montage Health can’t control its further dissemination
• I may revoke this authorization at any time. My revocation must be made through this online form or in writing, signed by me or on my behalf, and delivered in person or by mail to 20 Ragsdale Drive, Suite 201, Monterey, CA 93940. The revocation will be effective once you receive it, but will not be retroactive