Share My Story Name* First Last Email* Primary Cancer Diagnosis Chemotherapy Drug Regimen Treatment Center Name of Oncologist Name of Nurse City, State Ethnicity Age Your Experiences with DigniCapPlease tell us your storyUpload a photo to share with your story!Want to share photos or videos from your DigniCap journey? These can include before and after photos, photos of you wearing the DigniCap during treatment, or just a photo of you to share along with your story. *Photo(s) will be shared with your story. For best photo quality upload high-resolution photos, including at least one horizontal photo.Upload Photos Here Drop files here or Select files Max. file size: 2 MB. Upload Videos Here Drop files here or Select files Max. file size: 2 MB. If a reporter in your area is interested in doing a story on scalp cooling, would you be interested is speaking to them? Yes No ConsentConsent for Photos, Videos and/or Written StoryI hereby authorize Dignitana to utilize the photographs, videos and/or the written story that I have submitted for the following use: (Uncheck all that do not apply) Marketing (brochure and/or advertisements) Media (television, online and/or print) Web-based (still photos, web-based brochures, videos, etc. on any of Dignitana’s websites) DigniCap Patient Stories Page Social Media Other Other - Please Specify: Consent for Personal informationI hereby authorize Dignitana to use the following personal information in conjunction with my Patient Story. (Uncheck all that do not apply) First Name Last Name Age City State Treatment Facility Primary Diagnosis Drug Regimen Other Other - Please Specify: Want to share your story anonymously? Check the box below. Yes Authorization to use the above information*I give my authorization to use the above information in the manner set forth above and understand and acknowledge that: (i) although my name will not be published in any of the Production Materials, anonymity cannot be guaranteed, (ii) with this authorization, I release Dignitana from any and all liability that may arise from the use of the Production Materials consented to above, (iii) the Production Materials consented to above are the property of Dignitana and may be used in future projects, (iv) the Production Materials may be subject to re-disclosure by another party and thus may no longer be protected by HIPAA or under the terms of this authorization, (v) I will not receive any compensation if the Production Materials are released and/or used by Dignitana or any other party that may obtain the Production Materials in the future, and (vi) this authorization will expire fifty years from the date of this authorization. I do not have to sign this authorization and I may cancel this authorization at any time. If I do, Dignitana will take reasonable steps to cease using the Production Materials. However, I understand that by cancelling this Authorization, my cancellation will not affect the Production Materials disclosed by Dignitana prior to its receipt of my cancellation or with respect to any commitments made by Dignitana prior to its receipt of my cancellation. The cancellation is note effective to the extent that any person or entity has already acted in reliance on my authorization. I give my authorization to use the above information Photograph and Video Review* I have reviewed all photographs and video that I am submitting, with the understanding that they may be published, and agree to their use. Personal Information Review* I have reviewed and consented to the above use of my personal information.