This is to certify that I have chosen to give my testimonial as a patient of Clarke EyeCare Center.

I understand that by submitting my testimonial it does not guarantee the use of my testimony. I understand that by submitting my testimonial I give Clarke EyeCare Center the right to use my testimonial for reproduction in any medium including but not limited to; website, video, broadcast, print, and electronic means for purposes of advertising, trade, display, exhibition or editorial use.

The undersigned releases Clarke EyeCare Center from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity or any other claim. I hereby agree to have my name appear as is in any posting or publication.

I expressly understand and agree that the Materials and all results shall be the sole and absolute property of Clarke EyeCare Center for any and all purposes whatsoever in perpetuity; free and clear of all claims whatsoever by me and or on my behalf.

I hereby hold harmless and release Clarke EyeCare Center 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.

I have read the authorization and release information and give my consent for the use of my testimonial as indicated below