Janesi Comfort is always pleased whenpatients are willing to communicate the stories, experiences, and informationabout their or their family member's treatments. Sharing your story can helpothers who are interested in knowing more about your personal experiences andhelp Janesi Comfort promote it's mission of service.
Janesi Comfort respects the privacy of ourcustomers, visitors, and staff. Ensuring that medical information is keptconfidential is among our highest priorities. Janesi Comfort seeks yourpermission to use your stories and experience. Your consent allows us use thatmaterial you submit text/audio/video/photographic in Janesi Comfort’ internaland external communications, including medical and general interestpublications and medical and patient education information, and distribute suchmaterials online, in print, and in news media (such as social media, TV, radio,newspapers, and magazines).
To ensure that Janesi Comfort is acting inaccordance with your wishes, and using your personal information with yourauthorization, we ask you to accept this submission form. Janesi Comfort willnot accept submissions where this consent is not granted.
• If submitted, I do give my permission for Janesi Comfort to use my or mychild’s name and share details of my or his/her treatment and experience as apatient in communications produced by or on behalf of Janesi Comfort, andconsent make use of my and/or my child’s audio/ video/photographic images inpublications produced by or on behalf of Janesi Comfort. This permissionextends both to electronic versions on the Janesi Comfort websites and otherinternet/electronic applications as well as to printed, filmed, and tapedversions.
• If submitted, I give my permission forJanesi Comfort to release my or my child’s name and details of his/her medicalcare to the news and electronic media including, but not limited to,internet/online publications, TV, radio, newspapers and/or magazines, and allowthe news media to make images (text, digital, video, or otherwise) of me or mychild for purposes of illustrating my treatment and experience.
• If submitted, I specifically authorizethe release of information pertaining to alcohol, drug, and/or substance abuse,diagnosis, or treatment.
• If submitted, I specifically authorizethe release of information pertaining to mental health diagnosis or treatment.
• If submitted, I specifically authorizethe release of information pertaining to HIV/AIDS test results.