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  Contact : (607) 748-4151

Testimonial Release Form

  • Authorization and Release Information

  • I understand my testimonial as outlined above (the "Testimonial") and made on behalf of [Giordano Dental/Southern Tier TMJ & Sleep Therapy] (hereinafter called "The Company") may be used in connection with publicizing and promoting The Company. I authorize The Company to use my name, brief biographical information, and the Testimonial as defined on this form.
    I hereby irrevocably authorize The Company to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Company's programs or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against The Compay for the use of the statement.
    In addition, I waive any right to inspect or approve the finished product, included written copy, wherein my likeness or my testimonial appears.
    I hereby hold harmless and release The Company from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
  • Electronic Signature (E-Signature) Agreement

  • Electronic Signature:

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