First Name *

Last Name *

Date *

E-mail Address *

Testimonial *

Waiver and Release
Media Release THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. For good and valuable consideration, and effective as of today I hereby give and grant to Metagenics, Inc. and its affiliates and subsidiaries (“Metagenics”), without further conditions, the exclusive, royalty-free, transferable, assignable, sub-licensable, worldwide, unlimited right to use, re-use, reproduce, publish, distribute, re-publish, exhibit, edit, modify, adapt, prepare derivative works based upon, and otherwise exploit, my appearance, likeness, testimonial statements and health information in Metagenics' possession, or any portion thereof, in any and all media now known or hereafter devised (including, without limitation, television, radio, the Internet, mobile, wireless, and print media), for any and all marketing, advertising, promotional, educational, scientific, public relations and charitable purposes and materials about Metagenics, whether existing prior to, on or after the Effective Date (collectively, the “Materials”). I understand that my name and other details that would disclose my identity may also be revealed. I agree that no proposed use of the Materials need be submitted to me for any further approval, although I may have other rights, as explained below, that apply to my Protected Health Information (“PHI”) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I hereby release Metagenics, its authorized representatives, employees, attorneys, affiliates, subsidiaries, directors, officers, agents, successors, assigns and licensees from any liability or claims directly or indirectly relating in any way to their use of the Materials, including, without limitation, any claims for copyright infringement, defamation, invasion of privacy or right of publicity, so long as such use is in accordance with this agreement. I understand that the Materials may be altered, adapted, or modified in connection with such use. I consent to the editing of my testimonial statement by Metagenics and the attribution of such statement to me, so long as the edited version has substantially the same meaning as the original statement. I understand that I will not receive any royalties, reimbursement or other compensation for permitting Metagenics to use the Materials. I also understand that I will have no copyrights or other rights with respect to the Materials as they are used by Metagenics, including any rights to credit or attribution. I agree that all Materials will be owned by Metagenics and that Metagenics may claim copyright ownership over the Materials or any works including the Materials. I will sign any further documents that Metagenics may request to evidence, establish, maintain or protect its rights in the Materials. I represent and warrant that: (a) I have full power and authority to enter into and perform this Agreement, (b) I am the sole owner of all right, title and interest in my testimonials and my health information, including PHI (“My Information”) without any encumbrances of any kind beyond the requirements of HIPAA, (c) I am not aware of any actual or potential violation, infringement or misappropriation of any third party's rights (or any claim or potential claim thereof) by Metagenics' use of My Information, (d) I can enter into this Agreement without violating any rights of or breaching any obligations to any third party under any agreement or arrangement between myself and such third party, (e) no additional licenses, permissions, consents or releases of third party rights are necessary for Metagenics' use of My Information in accordance with the terms of this Agreement, and (f) neither I nor any third party has or will have “moral rights” in My Information or rights to terminate any assignment or license with respect thereto. I have not previously authorized, nor will I authorize or permit during the Term of this agreement, the use of the Materials without the express written approval of Metagenics. I understand that the materials being released to Metagenics may include PHI (Protected Health Information). I also understand that, under HIPAA, I have certain rights to access this information and the right to revoke this consent and release. Under these provisions, I may access the materials being released or I may revoke this consent and its release in writing, by addressing a letter to the following: Attn: HIPAA Privacy Officer, Metagenics, Inc., 25 Enterprise, Suite 200, Aliso Viejo, CA 92656. I understand that this release is effective as of the date of this release and expires ten (10) years from the date of this release. I understand this paragraph and the above provisions.

I agree to the terms and conditions above *
YesNo