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PhysioCue Migraine & Headache Device Survey
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By agree this release, I authorize PhysioCue, Inc. (“PhysioCue”), and their staff to distribute and share my testimonial, personal bio, photographs, video images, therapy profile (blood pressure data, migraine & headache pain related data) or other likenesses of myself, (collectively “Person information”) for the following purposes:1. Use in marketing, training and research and development activities and materials (including print and on line or electronic materials); and 2. Use in print or electronic form of PhysioCue publications, presentations, brochures, newsletters/bulletins, social media and websites for promotional purposes. I understand that my Personal Information may be included in, copied and distributed by means of various print or electronic media. I understand that my Personal Information will be included with or without the images or testimonials. I understand that this Authorization can be revoked at any time to the extent that the use or disclosure has not already occurred prior to my request for revocation. In order to revoke the authorization, I must notify PhysioCue in writing at the following address: PhysioCue, Inc.1798 Technology Dr. Suite #258 San Jose, CA 95110,
If I cancel this Authorization after publication of the materials outlined above, I understand that my cancellation may not be able to be honored. If I revoke this Authorization, PhysioCue shall not engage in any new uses or disclosures of my Personal Information. PhysioCue will not condition treatment, payment, enrollment or eligibility for services or benefits on the execution of this Authorization. I understand that the images and testimonials may be subject to re-disclosure by the person or entity receiving such information and thus will no longer be protected by federal privacy regulations. This Authorization is given without promise of compensation. My Personal Information becomes the property of PhysioCue and I release to PhysioCue, title and/or interest of the disclosed Personal Information produced or to be produced. I have read this document and understand its contents.
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