Authorization and Release of Testimonial Information 

I understand my testimonial as submitted below (the "Testimonial") and made on behalf of Procare Chiropractic & Sports Therapy PLLC (hereinafter called "Procare") may be used in connection with publicizing and promoting Procare. I authorize Procare to use my name, brief biographical information, and the Testimonial as defined on this form. 

I hereby irrevocably authorize Procare to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing Procare’s services 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 Procare for the use of the statement. 

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears. 

I hereby hold harmless and release Procare from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. 

If I wish to rescind my authorization, I will notify Procare in writing of that wish at that time.  The Testimonial will then be removed from all reasonably accessible publications (webpage, social media outlets) and will not be added to new publications. However It may continue to be present and used on  already created physical marketing materials (such as flyers, posters, post cards, etc).

 

Name *
Name
Phone *
Phone
It is our standard to use a first name and last initial, however if you wish for another option please select it here.
Which part of the Procare Team are you commenting about? *
I have read the authorization and release information and give my consent for the use of my testimonial as indicated above. *