Northwest Restorative Medicine desires to use and publicize the name, likeness, and other personal characteristics and private information of the individual named below (“I” or “me”) for use as a testimonial for services and health care provided by Northwest Restorative Medicine as part of its advertising, promotion, and other commercial and business purposes. In exchange for the intangible value I gained and will gain from the Product and by participating in Company’s publicity programs and other good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I give Company my permission for such use and publicity for such purposes.

I hereby irrevocably permit, authorize, grant, and license Company and its affiliates, successors, and assigns, and the employees, officers, directors, and agents of each and all of them, the rights to display, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my name, image, likeness, appearance, voice, professional and personal biographical information as part of a testimonial for the Product.

I represent and warrant to Company that I am at least eighteen (18) years of age, and I have full right, power, and authority to enter into this Agreement and grant the rights hereunder.