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Last Modified: June 25, 2013

This Patient Testimonial Release Agreement (the “Agreement”) is entered into as of the date and year set forth upon submission of the online website form located at hereof (the “Patient”), and Carolina Conceptions, P.A. (the “Company”).

Authorization and Release Information

The Patient understands that his/her Testimonial as outlined above made on behalf of the Company may be used in connection with publicizing and promoting the Company. The Patient authorizes the Company to use the Patient’s initials, image, likeness, voice, brief biographical information, and the Testimonial as defined in this Agreement.  The Patient agrees that the Patient will make no monetary or other claim against the Company for the use of the Testimonial. In addition, the Patient waives any right to inspect or approve the finished product, including written copy, wherein the Patient’s likeness or the Testimonial appears.

By submitting a Testimonial, you are agreeing to these terms. Please note that these terms may change from time to time. We will not reduce your rights under these terms without your explicit consent, and we expect most such changes will be minor. Regardless, we will post any changes on this page. Each version of these terms will be identified at the top of the page by its effective date, and we will also keep prior versions of these terms in an archive for your review.