RRI Employee Consent Form

EMPLOYEE CONSENT FOR USE IN PROMOTIONAL MATERIALS

I understand that my employer, Revival Research Institute, may use some of its staff, contractors, and other individuals in its promotional materials and website. This includes the name, credentials, and images of the physician practices, clinicians, researchers, and administrative staff in my employer’s advertisements and other promotional campaigns and material.

I also understand that if such consent is granted by me, that I, like others who have consented to the use of their likeness in promotional materials, may revoke this authorization at any time by a written request to my employer.

I also understand that I must give my own consent to appear in these promotional materials, which can be revoked at any time with notice given to my employer.

CHECK OFF ONE OF THE FOLLOWING