Consent to Use Image and Release

Consent to Use Image and Release

FOR GOOD AND VALUABLE CONSIDERATION, the receipt and sufficiency of which is hereby acknowledged, I grant to Twin Cities Pain Clinic and Andrew J. Will, M.D., P.A. (collectively referred to as “PRODUCER”), and their licensees and assignees all rights of every kind and character whatsoever in perpetuity throughout the universe in any and all languages in and to my image, name, likeness and/or voice and the results thereof (collectively the “Image”) in connection with the image utilized in the Twin Cities Pain Clinic website (the “Website”), and I hereby authorize PRODUCER to photograph and record (on file, tape, or otherwise), the Image; to edit same at its discretion and to include it with the images of others and with sound effects, special effects and music; to incorporate same into the Website or other media forms or not, to use and to license others to use such recordings and photographs in any manner or media whatsoever (whether now existing or created in the future-including future undiscovered technologies), including without limitation unrestricted use for purposes of publicity, advertising and sales promotion; and to use my name, likeness, voice, biographic and/or other information concerning me in connection with the Website, commercial tie-ups, merchandising, and for any other purpose. I further acknowledge that PRODUCER owns all rights to the results and proceeds of my services rendered in connection herewith.

I waive my right of inspection or approval of my appearance or the Image or the uses to which they may be put (including but not limited to any moral rights I have in the website). I acknowledge that PRODUCER will rely on this permission, at substantial cost to PRODUCER, and I agree not to assert any claim of any nature whatsoever (including but not limited to any claim for money, injunctive or other equitable relief of the right to revoke this grant of rights based on invasion of privacy or publicity, defamation, emotional distress or otherwise) against anyone relating to the exercise of the permissions granted hereunder. I understand that state and federal laws afford me certain rights as a patient. I am specifically waiving any privacy claims and/or privileges afforded to me as a patient by state and federal laws, in connection with the Images granted hereunder.

This Release shall be governed by the laws of the State of Minnesota, regardless of the place of its physical execution, and shall be binding on me, my legal representatives, heirs and assigns.

I represent and warrant that I have complete authority to grant this Release. This Release represents the entire understanding in effect between the parties regarding the subject matter.

ACCEPTED AND AGREED TO:

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