Patient Story & Media use

Respondent first name

Respondent last name

Email

Telephone

Are you

Patient’s full name if you are not the patient

How old is the patient?

Over 18

Under 18

An infant or toddler

Name usage

Use the patient’s full name

Use the patient’s first name only

Refer to the patient as anonymous

Use a pseudonym

Please outline your/the patient’s story

I consent to this story being used in the following contexts

On the DAA website and all DAA-owned print materials including Helipad magazine, marketing and fundraising materials

Devon Air Ambulance social media pages

Press releases

Names third party partners

Shared with Air Ambulance UK

All the above

Along with my story I also consent to the following being shared

Photographs

Video recordings

Audio recordings

All the above

Media interviews

I consent to being contacted for possible media interviews

I understand I can withdraw consent at any time and future use will cease.

I understand

I confirm I am participating voluntarily and can pause/stop at any time

I understand

For story subjects under 18 parental/guardian consent is required. Please state the parent/Guardian name:

Date parental/guardian consent given

If the patient is under 18 have they given their consent to use this story

Yes

No

Captcha

Our privacy statement explains how we use any personal information we collect from you.