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Patient Testimonial Release Consent

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SAN ANTONIO     |     SCHERTZ     |     SOUTH TEXAS                                           210-359-0051

Patient Testimonial Release Consent

Purpose of Consent: By signing this form, you are consenting to allow Joel A. Rodriguez, M.D., PLLC, dba RioSurgical Specialists of Texas, use and disclosure of the information in your testimonial and acknowledgement that the testimonial may be distributed to the public.

Authorization to Release Information

I understand my testimonial made on behalf of Joel A. Rodriguez, M.D., PLLC, dba RioSurgical Specialists of Texas (“RioSurgical”) may be used in connection with publicizing and promoting RioSurgical. I authorize RioSurgical, its agents or employees (or news media personnel), to use all or part of my testimonial, to photograph, film (i.e., motion pictures), videotape, produce other illustrative material and/or make audio recordings of me, provided that such photographs, film, motion pictures, videotape, audio recordings or other illustrative material be used only for education or informational purposes, which, in the judgment of RioSurgical, may help to further the goals of RioSurgical. These purposes may involve print, seminars, broadcast and web-based media.

I hereby irrevocably authorize RioSurgical to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing the company's programs 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 RioSurgical for the use of the testimonial information, my statements, image or likeness.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my likeness or my testimonial appears.

I hereby hold harmless and release RioSurgical 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.

By authorizing, I certify that I am of legal age and freely sign this release, which I have read and understood.