Authorization for Use of Images, Testimonials, and Content for Marketing and Educational Purposes

Purpose of this Authorization

This authorization allows Hanabusa IVF and its affiliates (“the Provider”) to use or disclose certain information, images, or content provided by me for marketing, promotional, or educational purposes. The intent of this authorization is to allow Hanabusa IVF to share authentic stories and patient experiences in alignment with its mission to educate and support others on their fertility journey.

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Information to Be Used or Disclosed

I authorize Hanabusa IVF to use the following materials that I voluntarily provide or that are created in connection with my care:

• Photographs, video recordings, or audio recordings of me.
• Written or recorded testimonials, quotes, or statements I provide.
• Images or content voluntarily submitted by me (including baby photos, milestone images, or “graduation” photos).

No medical records or identifying health information will be shared unless I have specifically and separately authorized it. Any materials used will be limited to those relevant to promotional or educational purposes.

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Authorized Uses and Disclosures

I grant Hanabusa IVF and its affiliates a non-exclusive, perpetual, royalty-free license to use, reproduce, publish, and distribute my testimonial, image, likeness, and content in any media format, including but not limited to:

• The Hanabusa IVF website and affiliated web pages
• Social media channels (e.g., Instagram, Facebook, YouTube, LinkedIn)
• Printed brochures, newsletters, and educational materials
• Presentations, digital advertising, and internal communications

All use will be consistent with Hanabusa IVF’s standards of professionalism and patient respect.

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Waiver and Release of Claims

I waive any right to inspect, approve, or claim ownership of the materials produced. I release and discharge Hanabusa IVF, its physicians, employees, agents, and affiliates from all claims, demands, or causes of action arising out of or related to the authorized use, including but not limited to claims of defamation, invasion of privacy, or infringement of publicity rights.

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Voluntary Consent and Revocation Rights

• I understand that this authorization is voluntary.
• My decision to sign or not sign this form will not affect my medical care, treatment, or eligibility for benefits.
• I may revoke this authorization at any time in writing by contacting Hanabusa IVF at [insert office address or HIPAA contact email]. Revocation will not affect any use or disclosure made before my request was received.

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