Patient – Case Study Consent Form Case Study Consent Form PATIENT NAME First Middle Last AUTHORIZED REPRESENTATIVE First Middle Last RELATIONSHIP TO PATIENT Self Spouse Parent Guardian PERMISSION TO RELEASE INFORMATION INCLUDING PHOTOGRAPHS, VIDEOS, ELECTRONIC OR OTHER MEDIA I give AxioBionics, LLC and agents acting on its behalf permission to use certain information about the above-mentioned patient for the purposes of education, public relations, marketing, and promotion of AxioBionics and its pain management and neuromuscular stimulation Wearable Therapy® Systems and TripleFlex™ Orthoses. This may include photographs, video, audio, testimony, name, medical case history and results/outcomes. The items may be used by AxioBionics and by the media indefinitely. I understand that I can revoke this permission at any time by contacting AxioBionics at 800-552-3539. However, I also understand that AxioBionics has no control over disclosures made before I revoke my permission. I understand that the released items will be used in various advertising and educational ventures such as seminars, training materials, the AxioBionics website, social media sites, email correspondence, advertisements, printed promotional literature, shared with news media for publication and/or broadcast and/or distribution via other means to the general public. I release AxioBionics, its agents and employees from liability for any and all claims by me or any third party in connection with my participation. I acknowledge that since my participation is voluntary, I will receive no financial compensation. I further agree that my participation confers upon me no rights of ownership whatsoever and the items may be destroyed at any time. I understand that I may refuse consent and that this decision will not affect the patient’s care.
