FormsRelease of Records Notice of Privacy Practices Acknowledgement of Privacy Practices Authorization to Share Information Form New Patient Survey New Patient Information Patient Health History – Adult Patient Health History – Child Testimonial Release Form Date* Testimonial Statement and/or Inventory of Testimonial Materials:*Authorization and Release InformationI 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.I authorize the Company to use:My testimonial, full name, town, cityMy testimonial, initials, town, cityFull Name*I have read the authorization and release information and give my consent for use as indicated above.*YesElectronic Signature (E-Signature) AgreementBy selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*I AcceptElectronic Signature:Name* First Last Today's Date* EmailThis field is for validation purposes and should be left unchanged.