Baptist Health 100th Anniversary Memory Box

Join Baptist Health in celebrating 100 years of providing quality patient-centered care to Arkansans with Christian compassion and personal concern. As we prepare for anniversary celebrations in the coming months, we want to hear how our healthcare system has impacted you. We wouldn’t be where we are today without your story shaping ours. 

Thank you for sharing your Baptist Health story.

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By clicking the "Submit" button, you are giving consent for Baptist Health's Marketing and Communications Department to contact you for further information.

Marketing and Communications representatives reserve the right to edit text for length, style, and sensitive information.

This form is being used to obtain authorization from you to release to the public photograph(s) and/or information that is related to your care, condition and treatment as a patient of Baptist Health (in response to media inquiries and/or in news releases and reports, publications, marketing materials and/or the website). 

I hereby authorize and permit Baptist Health to take, obtain and make use of photography and publicity of myself and to release information I provide regarding my health, status, care, condition and treatment as a patient of Baptist Health.

  • I understand that such photography, interviews and information may be used for inclusion in media reports, Baptist Health publicity materials (advertisements, billboards and publications), the Baptist Health website (baptist-health.com) and other publicity avenues.
  • I understand that media reports and Baptist Health publicity materials are widely distributed and made available throughout Arkansas and eastern Oklahoma.
  • I understand that once the provided information has been disclosed in accordance with this authorization, it may be further shared/disclosed by individuals or organizations other than Baptist Health.
  • I understand that no compensation will be provided to me for this release.
  • I understand that I have the right to request cessation of filming or recording after my authorization has been given.
  • I understand that this authorization may be revoked by writing to Baptist Health, Marketing & Communications, 9601 Baptist Health Drive, Little Rock, AR 72205.
  • I understand that upon revocation, Baptist Health will make reasonable efforts to discontinue the release of this information/photograph whenever possible except where materials are in the process of or have been printed, displayed and/or disseminated to the public.