Patient Stories Release Agreement
By submitting my Patient Story to the online form at www.sanctuaryfunctionalmedicine.com, I hereby grant Sanctuary Medical Care and Consulting (dba as Sanctuary Functional Medicine) the irrevocable right and permission to use photographs, video recordings, audio recordings and/or testimonials of me on Sanctuary Functional Medicine websites, in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.
Right to Revoke: You have the right to revoke this Release at any time by providing written notice of your revocation and submitting it to the contact person listed below. Please understand that revocation of this release will not affect any action Sanctuary Functional Medicine took in reliance on this release before receiving your revocation.
I understand and agree that such photographs, video recordings, audio recordings and/or testimonials of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Sanctuary Functional Medicine.
I hereby release, acquit and forever discharge Sanctuary Functional Medicine, its current and former owner (s) and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs video recordings, audio recordings and/or testimonials including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.
I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.