The team at Hill-Rom Respiratory Care would love to hear from patients and their caregivers about how their Hill-Rom® product has changed their life. Fill out the simple form below and a member of the Hill-Rom Respiratory Care team may contact you.
©2016 Hill-Rom Services PTE Ltd. ALL RIGHTS RESERVED.
198586 rev 1 14-JULY-2016 ENG – US
TERMS & CONDITIONS**
I hereby authorize Hill-Rom to copy, exhibit, publish or distribute my testimonial and my photograph/video (“Image”) for purposes of marketing, publicizing Hill-Rom’s products or services, or for any other lawful purpose. My testimonial and/or Image may be used in printed publications, multimedia presentation, on websites or in any other distribution media. I hereby waive the right to inspect or approve the finished product, including any written copy, wherein my testimonial appears. I waive any right to royalties or other compensation arising from or related to the use of my testimonial and/or Image. I understand that while I am providing testimonial information to Hill-Rom, my treating healthcare provider(s) shall not, at any time, provide any protected information to the media or to the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). I hereby hold harmless and release Hill-Rom, its officers and employees from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
Right to Revoke
I hereby acknowledge that I have the right to revoke this Release at any time by contacting customer service to give Hill-Rom written notice of my revocation. I understand that revocation of this Release will not affect any action that Hill-Rom has taken in reliance on this Release before receiving my revocation. By clicking the check box in the form below, I hereby acknowledge and agree that I have read and understand the above Release and agree to all terms described. I further acknowledge that I am of legal age and have voluntarily signed this Release.