Testimonial Submission and Release Form

Your name

Date of Service:

Provider You Saw

Smitha Kumar, MD Maria Jumagdao-Sakai, MD

Testimonial:

Authorization and Release Information

I understand my testimonial as outlined above (the "Testimonial") and made on behalf of Gilroy Family Medical Group (hereinafter called "GFMG") may be used in connection with publicizing and promoting GFMG. I authorize GFMG to use the date provided and the Testimonial as defined on this form.

I hereby irrevocably authorize GFMG to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing GFMG'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 GFMG for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my likeness or my testimonial appears.

I hereby hold harmless and release GFMG 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.

Signature:

I have read the authorization and release information and give my consent for the use as indicated above.

Signature:

Address:

City:

State:

Zip:

Telephone:

Today's Date:

Your information will be encrypted.