Media Release Form

I hereby authorize DOVE Transplant to use and disclose my Private Health Information (PHI) obtained through interviews, photographs, written communications to the general public for the following purposes:

• Print and online distribution of recipient and donor campaigns, flyers, updates (DOVE Social Media sites, print publications, email publications and communications, brochures, website usage)

• Broadcast, print and online news media

• Educational materials, videos or presentations

• Fundraising communications.

I give permission to DOVE to disclose my PHI obtained through interviews, photographs, written communications for the above reasons.