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 Clinics. 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 *

Date of Birth of Minor Patient or Person *

Relationship to Minor Patient or Person *

Phone Number *

Email Address

Zip Code *

Today's Date *

Signature of Consenting Individual, Parent or Guardian *

Type of Consent *
Consent is ongoingConsent is for one-time use only

Physical Signature in lieu of Electronic Consent
Paper copy on file at 308 North Peters Road, Suite 225 Knoxville, TN 37922

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