Recovery Index Form Submission Program Terms

The undersigned (“Product User” or “you”) agrees that, pursuant to the terms of this CONSENT FOR RELEASE AND USE OF PHOTOGRAPHS, VIDEOS, AND TESTIMONIALS (this “Consent”), POWERHEAL WOUNDS, LLC, an Arizona limited liability company (the “Company”), is hereby authorized to use and disclose the Media (defined below) in connection with the Company’s educational, research, promotional, and commercial activities relating to wound care as well as inclusion in the “Recovery Index” section of the Company’s website (the “Purpose”). 

In consideration of the terms and conditions set forth below, the Company and hereby agree as follows:

  1. I hereby grant to the Company the following rights: (i) to use case studies, records, notes, descriptions, videos, photographs, testimonials, and audiotape which I provide to the Company in connection with the Purpose (collectively, the “Media”); (ii) the right to store digitally or otherwise reproduce the Media and to present the Media, and any content contained therein or associated therewith, in whole or in part, in connection with the Purpose; and (iii) to combine the Media with other images, text, and graphics, and crop, alter, or modify the Media, in the Company’s sole and absolute discretion.

  1. The Company agrees that it will only use and present the Media in connection with the Purpose; provided, however, the Company will have no obligation to use any Media submitted and may elect to return or destroy any Media, in its sole and absolute discretion, for any or no reason and without further notice to Product User.

  1. Although the Media will be used without identifying information such as my name, I understand the the Media may be seen by the public and someone may recognize me. I agree that the Company cannot guarantee that I will not be recognized in any Media or any use thereof.

  1. I acknowledge and agree that: (i) I will not be entitled to any monetary compensation or other consideration for the rights granted in this Consent from the Company or any other party; and (ii) my treatment, payment, enrollment, or eligibility for benefits provided by a third party will not be affected by or conditioned on whether I sign this Consent. I further understand that any Media and other information used or disclosed about me pursuant to this Consent may be subject to re-disclosure by the Company or its recipients and will no longer be protected by federal or state law, including, without limitation, the Health Insurance Portability and Accountability Act of 1996.

  1. I understand that I have the right to revoke this Consent, in writing, at any time, except to the extent that the Company has acted in reliance upon it, by sending written notification to: I further understand that the Company, as well as other entities, may retain copies of any electronic or printed materials containing the Media and shall retain these versions forever and that any revocation of this authorization will only extend to the versions of the Media or other information within the Company’s control. If not earlier revoked by me, this authorization will not terminate or expire.

If this Consent is agreed to by a legal guardian or authorized representative of the person in photographs, videos, or testimonials, the legal guardian or authorized representative hereby represents and warrants to the Company that he/she/it is the legally authorized representative of the Product User and will indemnify, defend, and hold harmless Company from any and all claims, damages, liabilities, losses, costs, and expenses arising out of a breach of the foregoing warranty.

If I have any questions or wish to withdraw my consent in the future, I may contact: