I understand my testimonial as outlined above and made on behalf of IHCS may be used in connection with publicizing and promoting IHCS. I authorize IHCS to use my name, practice/agency name, brief biographical information, and the Feedback provided on this form. I authorize IHCS to copy, exhibit, publish or distribute this information for purposes of publicizing IHCS’ programs or for any other lawful purpose. These statements 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 IHCS for the use of this information. In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my likeness or my testimonial appears. I hereby hold harmless and release IHCS from all claims, demands and causes of action which I, my representatives, administrators or any other persons acting on my behalf or on behalf of the named practice/agency have or may have by reason of this authorization.

I have read the authorization and release of information and am authorized to give consent for the use as indicated above.