Patient Testimonial Terms

This is to certify that I have chosen to give my testimonial as a patient of Segal Institute for Clinical Research.

I certify that I have participated as a volunteer in a research study at Segal Institute for Clinical Research.

I understand that by submitting my testimonial it does not guarantee the use of my testimony. I understand that by submitting my testimonial I give Segal Institute for Clinical Research the right to use my testimonial for reproduction in any medium including but not limited to; website, video, broadcast, print, and electronic means for purposes of advertising, trade, display, exhibition or editorial use.

I understand that by agreeing to the terms, it releases Segal Institute for Clinical Research from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity or any other claim. I hereby agree to have my name appear as is in any posting or publication.

I certify that I am an adult (over the age of 18) and fully authorized to agree to these terms.

I have read these terms, or have had it read to me, and I understand all of the information on it.