Consent and Release Form for Photographing, Videotaping, Quoting and Interviewing
I hereby consent to be photographed, filmed, videotaped, quoted and/or have my personal likeness recorded through other visual means (collectively, referred to as “Personal Images and Quotes”), and authorize Sonex Health, Inc. and/or its affiliates and authorized agents (collectively, “Sonex”) to use, release, publish, exhibit, disclose, post on the Internet, or any other medium any of my Personal Images and Quotes, as described below and understand and acknowledge by signing this consent and release form the following:
By signing this form, I hereby give permission to Sonex to publish, disclose and/or use my Personal Images and Quotes for internal purposes, and external purposes including through publication on Sonex’s websites, social media, education videos, power-point presentations, brochures or other materials, in lectures and presentations at professional conferences, marketing materials and discussions with medical professionals (collectively, referred to as “Authorized Purposes”).
I understand that my Personal Images and Quotes may be seen, published, disclosed and used by Sonex throughout the world and hereby consent to such worldwide publication, disclosure and/or use of such Personal Images and Quotes for the Authorized Purposes. I understand that my consent is voluntary, that I am not required to sign this consent and release form and that I may in fact refuse to sign it, thereby prohibiting Sonex from obtaining, publishing, disclosing and/or using any Personal Images and Quotes of me.
I have the right to revoke my consent allowing Sonex to publish, disclose and/or use my Personal Images and Quotes at any time by sending written notice to Sonex. If I revoke this consent, Sonex will no longer use or disclose my Personal Images and Quotes, except to the extent it has already relied upon this authorization. Written notice of revocation must be sent or emailed to the following:
Vice President of Marketing
950 Blue Gentian Rd, Suite 200
Eagan, MN 55121
info@sonexhealth.com
I release and discharge Sonex, its officers, agents, employees and each and all persons involved in creating my Personal Images and Quotes from any liability connected with the taking, recording, filming, production, disclosing and/or publishing of such photographs, slides, computer images, videotapes and/or quotes.
I waive all rights I may have claims to for payment or royalties in connection with any exhibition, televising, internet posting, or other publication or otherwise the disclosure of my Personal Images and Quotes, irrespective of whether a fee for its use is charged by any third party.
I waive all rights I may have to inspect and/or approve the use of my Personal Images and Quotes or any reproductions thereof, by Sonex.
If I have any questions about my privacy rights under this consent and release form, I understand that I may contact Sonex. I declare that I am eighteen (18) years old or older and am legally competent to execute this consent and release form or that I have acquired the written consent of my parent or legal guardian. I understand that the terms herein are contractual and not a mere recital, and that this consent and release form is legally binding on me.
I have read and fully informed myself of the contents of this consent and release form before signing it. I have had the opportunity to ask questions about the disclosure, publication and/or use of my Personal Images and Quotes, understand their intended use, knowingly consent to the publication, disclosure and/or their use and voluntarily sign this consent and release form.
