Patient Registry Testimonial Confidentiality Agreement

Background

You are a participant in the Dizziness, Vertigo, and Imbalance Patient Registry (the “Registry”), a research initiative managed by the Vestibular Disorders Association (“VeDA”). When you enrolled in the Registry, you signed a consent form stating that any personal health information you provided would remain confidential and de-identified in all research uses and publications.

You have now voluntarily agreed to participate in a video testimonial describing your personal experience as a vestibular patient and as a participant in the Registry. This testimonial may include your first name, likeness (image), voice, and statements, and may be shared publicly for educational, advocacy, and outreach purposes.

Purpose of this Release

By signing this form, you authorize VeDA to use your testimonial and to identify you by first name and image, acknowledging that you are a vestibular patient who has participated in the Registry. This authorization applies only to the use of your testimonial for public communications and does not alter the confidentiality protections governing your health information within the Registry itself.

Authorization and Release

I, the undersigned participant, hereby:

1. Acknowledge and understand that my Registry participation data will continue to remain de-identified and protected under the Registry’s confidentiality policies.
2. Authorize VeDA to record, reproduce, publish, and distribute my testimonial, including my first name, image, likeness, and voice, in whole or in part, through any media (including but not limited to VeDA’s website, social media, print materials, presentations, educational programs, and media interviews).
3. Acknowledge that by choosing to appear on video, I am voluntarily releasing VeDA from its obligation to maintain my anonymity in this specific instance, and that members of the public may recognize me as a vestibular patient and Registry participant.
4. Understand that no payment or other compensation will be provided for the use of my testimonial.
5. Acknowledge that I may withdraw my consent for future use of the video at any time by notifying VeDA in writing at [email protected]. Upon withdrawal, VeDA will make reasonable efforts to remove my testimonial from future materials, though materials already published or distributed prior to withdrawal may remain in circulation.
6. Release and hold harmless VeDA, its employees, contractors, officers, and partners from any and all claims, demands, or causes of action arising out of or related to the authorized use of my testimonial as described herein.

Duration of Authorization

This authorization will remain in effect until revoked in writing. Revocation will not affect any prior use or disclosure made before VeDA receives written notice of withdrawal.

Acknowledgment

I have read and fully understand this Confidentiality Release and Authorization. I am signing it voluntarily and have had the opportunity to ask questions about its contents. I understand that by signing below, I waive certain confidentiality protections that would otherwise apply under the Registry’s participant consent form for this specific purpose only.