Share Your Story Fill out the form below to share your photo and/or story First Name*Last Name*Email Address* Phone NumberPostal / Zip Code*ExperienceAttachment Drop files here or Accepted file types: jpg, pdf, doc, docx, txt, tif, tiff, png. Consent* I have read and understand this Consent and Release and I am over the age of 18. I also understand that my electronic signature is legally binding, and that I have the right to receive a paper copy of this signed consent at no cost by contacting us. Electronic Signature*(Please sign by typing your name in the following format: "/s/ FirstName LastName")Date* I hereby irrevocably give NxStage Medical, Inc. and its agents, employees, affiliates, licensees, successors and assigns (the “Company”), permission to use, display, copy, reproduce or publish, in whole or in part, interviews, photograph(s) and/or videotape recording(s) taken of me by the Company or its representatives, as well as information, oral or written statements, photographs, film, audio recordings, illustrations, or videotape images provided by the undersigned to the Company before and after the date set forth below, forevermore and for all purposes, including but not limited to, dissemination to employees, clients, health professionals, customers and members of the public for educational, research, scientific, public relations, marketing, and any other bona fide business purposes, and that such dissemination may be accomplished in any manner deemed appropriate by the Company. The Company is also permitted, although not obligated, to include my name as a credit in connection with the activities authorized by this Consent and Release. The Company is not obligated to use any rights granted in this Consent and Release. The undersigned, and his or her successors or assigns hereby release and hold the Company harmless from and against any and all claims, demands, and actions, and any liabilities, damages, or expenses resulting therefrom arising directly or indirectly from the activities authorized by this Consent and Release, including without limitation claims of defamation, invasion of privacy or infringement of moral rights, rights of publicity or copyright. The term “photograph” as used in this Consent and Release shall mean still photography or motion picture in any print or media format, as well as videotape, video disc, digital and any other mechanical or electronic means of recording and reproducing images. If these photographs, films, illustrations, audio recordings, web sites or videotapes are registered for copyright, I hereby assign said copyright to the Company.*By clicking submit on this form you understand you are giving NxStage permission to use, edit as necessary, and share your story. If needed, NxStage may contact you using the information provided above. This iframe contains the logic required to handle Ajax powered Gravity Forms.