Healthcare Webinar

Healthcare Webinar Participation & Recording Consent

Webinar Details

Webinar Title:

Date:    Time:    Presenter:

Participant Information

Emergency Contact

Insurance & Professional Information

Medical History (Optional but relevant to participation)

Consent, Recording, Use of Materials, and HIPAA Acknowledgment

By checking the boxes below and signing this form, the participant acknowledges, agrees, and authorizes as follows:

I consent to audio and video recording of my image, voice, and presentation during the webinar, and authorize the organizer to use such recordings for educational, promotional, and archival purposes. I understand recordings may be edited and used in whole or in part.

I confirm that I will not disclose identifiable protected health information of any third party during the webinar. I understand that any patient information shared must be de-identified in accordance with applicable privacy standards.

I acknowledge that the organizer will make reasonable efforts to remove direct identifiers if clinical examples are used, but that residual risk may remain. I release the organizer from liability for inadvertent disclosure of de-identified clinical examples when that disclosure complies with this agreement.

I grant permission for my recorded image, comments, slides, and contributions to be used, reproduced, and distributed in training materials, print, electronic, and broadcast media without compensation. This authorization is worldwide, royalty-free, and perpetual unless revoked as provided below.

Revocation: I understand that I may withdraw this authorization by delivering a written notice to the organizer at any time. Revocation will not apply retroactively to materials already produced, disseminated, or legally relied upon prior to receipt of revocation. Authorization expires on:

Educational Content, CE Credit, and Disclaimer

This webinar is offered for educational purposes only. Content is not intended to constitute medical advice, diagnosis, or treatment. Participant agrees to seek independent professional judgment before applying clinical content. The organizer disclaims any liability for application of information covered in the webinar.

I am requesting continuing education credit for this activity. License/Registration Number:

Certificates: Certificates of attendance will be issued only to participants who register, attend the required portion of the webinar as set by the provider, and complete any required post-activity evaluations within the stated time frame.

Cancellation, Fees, and Refunds

If a registration fee applies, it will be charged as indicated at registration. Cancellation requests must be submitted in writing. Refunds, if permitted, will be handled in accordance with the organizer's stated policy. The organizer reserves the right to cancel or reschedule the webinar; in such event, the organizer's liability is limited to the refund of the registration fee.

Data Retention and Contact Preferences

Participant contact information and registration details will be retained for administrative, accreditation, and notification purposes. By checking the box below you consent to receive administrative emails related to this webinar.

I consent to receive administrative and follow-up emails related to this webinar.

Attestation

I attest that the information provided on this form is accurate and complete to the best of my knowledge. I have read and understand the terms above, including the uses of recorded materials, privacy expectations, and my rights to revoke authorization prospectively. I accept the terms and conditions of participation in this webinar.

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