Authoriza*on and Release
I understand that I am voluntarily allowing my tes*monial, image, name, and other specific informa*on related to care from [Doctor or Prac*ce Name] (hereinaCer called "The Company") may be used in connec*on with publicizing and promo*ng The Company. I authorize The Company to use my name, brief biographical informa*on, and the Tes*monial as defined above. I hereby irrevocably authorize The Company to copy, exhibit, publish or distribute the Tes*monial for purposes of publicizing The Company's programs or for any other lawful purpose. These statements may be used in printed publica*ons, mul*media presenta*ons, on websites or in any other distribu*on media. I agree that I will make no monetary or other claim against The Company for the use of the statement. In addi*on, I waive any right to inspect or approve the finished product, including wriMen copy, wherein my likeness or my tes*monial appears. I hereby hold harmless and release The Company from all claims, demands and causes of ac*on which I, my heirs, representa*ves, executors, administrators or any other persons ac*ng on my behalf or on behalf of my estate have or may have by reason of this authoriza*on.
Signature: ______________________________________________________________
I have read the authoriza*on and release informa*on and give my consent for the use as indicated above.
Printed Name: _________________________________________
Signature: _________________________________________
Address: _________________________________________
City, State, Zip: ________________________________________
Telephone: _________________________________________
Date: _________________________________________
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