I give Laser Eye Institute, (herein, “LEI”), its employees, designees, agents, independent contractors, legal representatives, successors and assigns, and all persons for whom or through whom it is acting, the absolute right and unrestricted permission to take, use my name, testimonial and biographical data and/or publish, reproduce, edit, exhibit, project, display and/or copyright photographic images or pictures of me, whether still, single, multiple, or moving, or in which I (they) may be included in whole or in part, in color or otherwise, through any form of media (print, digital, electronic, broadcast or otherwise), for art, advertising, marketing, publicity, archival or any other lawful purpose. I waive any right that I may have to inspect and approve the finished product that may be used or to which it may be applied now and/or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of said items.
I release and agree to hold harmless LEI, its employees, designees, agents, independent contractors, legal representatives, successors and assigns, and all persons for whom or through whom it is acting; from any and all liability, whether intentional or otherwise, that may arise from or related to the use of my name, testimonial and biographical data, clinical outcome data, photographic images or pictures of me, whether still, single, multiple, or moving, or in which I (they) may be included in whole or in part, in color or otherwise, through any form of media.
I understand this release may impact my rights under HIPAA and provide the following authorization for use of protected health information. I authorize LEI to use and disclose the following protected health information: first name, last name, pre-operative prescription, post-operative prescription, type of procedure. This authorization becomes effective on the date of this release with no expiration. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I understand that revocation of this authorization will not revoke or otherwise impeach the terms outlined in paragraphs one (1), two (2), and four (4).
I certify that I am at least 18 years of age and that this release is signed voluntarily, under no duress, and without expectation of compensation in any form now or in the future.