AUTHORIZATION AND RELEASE

For Media/Public Relations and Marketing Purposes

I have engaged with LERA Health (“Provider”) and their functional medicine offering. I have voluntarily elected to provide Provider with feedback concerning my overall experience or specific aspects of my health journey with Provider. I grant Provider permission to use content created about my experience in any form including video, audio, and/or written. I authorize Provider to: (a) take photographs, films, audio, or video, (b) interview me, and/or (c) publish articles or information about me concerning my interaction with such practitioners/staff. I understand that the feedback that I provide and the related photographs, interviews, etc. may include information about treatments that I have received from Provider and I authorize Provider to use this information as described below.

I grant Provider a perpetual, unlimited license and the absolute right and permission to reproduce, use, and broadcast my feedback along with photographs or likenesses of me, as well as use my name and any associated statements, comments, and/or oral recordings that I may provide, in connection with my feedback while advertising Provider products and services. I understand that these materials may be used across all marketing channels, including television, online, print, radio, all for an unlimited time period. Additionally, I understand that the content I create related in any way with the services of the Provider can only be released on my personal social channels and my networks in coordination with the Provider’s team. I understand that I will receive no compensation for the use of these materials now or in the future and that Provider may use these materials until I have properly revoked this Authorization.

I may revoke this Authorization by providing written notice of revocation to Provider at: P.O. Box 16242, Golden, CO 80402 or to Provider’s email at support@lerahealth.com. Provider will have a reasonable period of time to act on the revocation concerning future uses, but the revocation will not have any effect on any action taken by Provider in reliance on this authorization before it received my written notice of revocation.