Patient Testimonial Release Consent

Purpose of Consent: By signing this form, you are consenting to Vold Vision, PLLC (Hereinafter, “Vold Vision”) use and disclosure of the information in your testimonial, photographs, and video recordings, and acknowledge that all content may be distributed to the public or to private entities.

I hereby irrevocably authorize Vold Vision to copy, exhibit, publish or distribute all testimonials, photographs, and video recordings for purposes of publicizing its services or for any other lawful purpose. These statements, photographs, and video recordings may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against Vold Vision for the use of this content.

I hereby authorize Vold Vision to use my testimonials, photographs, and video recordings for any lawful purpose. I understand and approve the disclosure by Vold Vision of testimonial information, photographs, and video recordings to the media and other individuals and entities that may be involved in Vold Vision’s advertising and media efforts.

I understand that I am providing the testimonial content and that my treating physician will not be providing any information for the testimonial, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including, Health Insurance Portability and Accountability Act (HIPAA).

I waive the right of prior approval and hereby release the Vold Vision from all claims for damages of any kind based on the use of my testimonials, photographs, video recordings, or information in the testimonial. I have had sufficient time to consult with independent legal counsel, and freely waive my right to do so. I am of legal age and freely sign this release, which I have read and understood.