Consent to Release

I, the undersigned, do hereby grant to Dr. Radkey and/or my Website Administrator (Brooks Jeffrey Marketing Inc.) the right and license to use and to authorize use of patient testimonial information for any purpose related to Dr. Radkey; to edit and incorporate the testimonial information into any production related to Dr. Radkey, at the discretion of Dr. Radkey, in any manner or media, in its public relations and marketing campaigns.

I understand that I am providing the testimonial information to Dr. Radkey and that she will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).

I waive the right of prior approval and hereby release Dr. Radkey and her agents and assigns from any and all claims for damages of any kind based on the use of my testimonial or information in the testimonial.

Right to revoke: I understand I have the right to revoke this Release at any time by providing written notice of my revocation and submitting it to Dr. Radkey. I understand that revocation of this Release will not affect any action Dr. Radkey took in reliance on this Release before receiving my revocation.

By signing below, I agree and acknowledge that I have read and understood this Release and agree to all terms described. I am of legal age and freely sign this Patient Information for Dr. Radkey and/or its agents and assigns.