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Patient Testimonial Consent

Image, Likeness, and Voice Recording Usage:

I grant permission to the rights to use my image, likeness, and sound of my voice as recorded on audio or video tape without payment or any other consideration to SonoSpine, LLC (“SonoSpine”) and my image, likeness, and recordings may be copied and distributed by various forms of media. I understand that my image may be edited, copied, exhibited, published, or distributed and I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that my image, likeness, and recordings may be used for, including, but not limited to, research, education products, presentations, marketing, advertising, publication, and other educational resources may be used in diverse educational settings within an unrestricted geographic
area.

I agree and acknowledge that I have read, understand, and agree to be legally bound by the terms of this release. I further agree and acknowledge that I am 18 years of age or older and that my signature below legally binds me to the terms of this release.

By clicking the button, you will leave the sonospinesurgery.com website and will be redirected to upload your MRI to our provider.

Our Practitioners’ MRI review is an informational review of the MRI images and/or report that you provide to us. , This is not a form of diagnosis, treatment, correction, prevention or medical care. As such, the Practitioner’s MRI review should not be used as a determinant factor in any person’s physical or other health care, health treatment or health maintenance. No information provided by or through the Practitioner’s MRI review should ever be considered a substitute for any professional health care services, and you should consult with one or more appropriately licensed, registered and certified physicians, surgeons or other health care professionals for the same. In arranging for a Practitioner to provide an MRI review, neither Sonospine® nor that Practitioner assumes any responsibility whatsoever, nor shall Sonospine® or such Practitioner in any event or under any circumstances be liable in relation to your decision concerning your health care, health treatment or health maintenance, including without limitation any actions that you choose to take as a result of the Practitioner’s MRI review. A diagnosis and a final determination of whether you may benefit from treatment at Sonospine® can only be made after you have been physically examined in person by one of our Practitioners.