Marketing Authorization and Release
I understand my name, likeness and details of my testimonial of Apple Healthcare Group may
be used in connection with publicizing and promoting the practice. I authorize The Practice to
use my name, brief biographical information, and the Testimonial as defined on this form. I
hereby irrevocably authorize The Practice to copy, exhibit, publish or distribute the Testimonial
for purposes of publicizing The Practice’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 The Practice
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 have read the authorization
and release information and give my consent for the use and disclosure of my information as
indicated above.