Tell Us Your Story

Contact information:

First name *: Last name *: Email address *: Email confirmation *: City: State:

Phone:

Your experience:

Please tell us about your experience with RespirTech *:

Share a photo to include with your story (JPG/GIF/PNG Only, 2MB Max)

If you would like to contact us by phone with any questions, call us during business hours (8:00 a.m. to 5:00 p.m. CST, Monday through Friday), or you can leave a message after hours and we'll return your call the next business day. Call toll-free at 800.793.1261 or 651.379.8999.

Thank you for providing your contact information, our team may use this to contact you to follow-up on your story

If you’re inquiring from outside of the United States, please call our customer care team: 800.793.1261

* Required Fields

Authorization:

* I agree to the following Terms and Conditions. Respiratory Technologies Inc., d.b.a. RespirTech, a Philips Company (RespirTech) appreciates your willingness to share your name, likeness, statements and testimonials that may contain personal information and protected health information with us (“Personal Information”). This Authorization and Release explains the purpose for collecting your Personal Information, and how RespirTech may use the Personal Information, you are choosing to share with us. This Authorization and Release also contains important terms and conditions associated with your agreement to grant RespirTech and its affiliates, licensees, vendors and sub-vendors the right to use your Personal Information as described below.

RespirTech is collecting Personal Information including short testimonials, photos and/or video so that RespirTech may share your experience with others. The names, statements, testimonials, photos, video and other information that are selected to be published could be used on a RespirTech or affiliate website, in printed materials, or may be used in other media or for other promotional activities. You hereby consent to photos and video to be taken of you by RespirTech. All photos and video will be the sole property of RespirTech. You hereby grant RespirTech the absolute right to use your likeness and the photos and video, in whole or part, with any alterations, including changes in character, form, composition, color or perspective, together with or without written copy, for the purposes described herein.

By signing this authorization and release, you hereby consent, to and grant to RespirTech and its affiliates, licensees, vendors or sub-vendors, the royalty free, perpetual right to copy, use, display, reproduce, broadcast, exhibit, license and/or publish in any medium now known or hereafter discovered (e.g., print, video, audio, internet, broadcast, digital or electronic, etc.), throughout the world, the Personal Information including but not limited to photos, video, statements, testimonials or other information, with or without your name, for any lawful purpose whatsoever, including but not limited to advertising, commercial, promotional or publicity purposes, free of any right of publicity or other claim by you that might restrict their free use by RespirTech. You hereby release and discharge RespirTech, its affiliates and their respective employees, licensees, vendors and sub-vendors, and all persons acting on their behalf or under their direction or authority, from any liability arising out of or relating to said use of your Personal Information including but not limited to your name, photos, video, statements, testimonials or other information in any medium including, but not limited to, claims relating to defamation, slander, rights of privacy or publicity, libel, copyright, or otherwise. You also waive any right to inspect and/or approve the photos, video or any materials incorporating the photos, video, statements, testimonials or other information and/or any use to which it is put. You further hereby waive any fee, royalty or other compensation from RespirTech or from any publisher for the photos, video, recording or performance given, or for the use of the rights granted herein or in any republication, reprint, transcription, electronic medium, or recording or any derivative thereof.

You understand the information disclosed by this authorization may be subject to re-disclosure by anyone receiving it, and the information disclosed will no longer be protected by HIPAA. You understand that RespirTech may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization form. Additionally, you understand that you can obtain a copy of RespirTech’s Privacy Policy by contacting RespirTech’s customer care team at 800.793.1261 or going to RespirTech’s website at respirtech.com. Your signature also indicates that you have received a copy of this authorization Form.

Except as to actions already taken by RespirTech in reliance on this authorization, you may revoke this authorization at any time by submitting a notice in writing to RespirTech:

RespirTech
Attn: Compliance Officer
5905 Nathan Lane North Suite 200
Plymouth, MN 55442

In the event that RespirTech has relied on this Authorization to create promotional materials featuring Personal Information released pursuant to this Authorization, you understand and agree that RespirTech shall retain the right to use the Personal Information until such time as all such promotional materials then in existence at the time of any revocation or termination of this Authorization are distributed, disseminated or expire.

BY SIGNING, I CONFIRM THAT: (1) I AM OVER TWENTY-ONE YEARS OF AGE, (2) I AM UNDER NO LEGAL DISABILITY, (3) I HAVE THE ABILITY TO CONTRACT IN MY OWN NAME CONCERNING THE SUBJECT OF THIS AUTHORIZATION AND RELEASE, AND (4) I HAVE READ, UNDERSTAND AND AGREE TO THIS AUTHORIZATION AND RELEASE.