TESTIMONIAL, PHOTOGRAPH and VIDEO RELEASE FORM

I, the undersigned, grant permission to Women's Care of Wisconsin to use my testimonial, photographs, and/or videos for marketing activities for publicity, promotion, illustration, advertising, brochures, social media and web content free of charge and for an indefinite period of time.

In giving this consent, I release Women's Care of Wisconsin and all third parties from liability claims based on the use of said testimonial, photographs and/or video images. I understand that the information used or disclosed for marketing purposes may be subject to redisclosure by the marketer and no longer protectable.

I understand that I have the right to revoke this authorization at any time by providing a written revocation to the Privacy Officer or designated staff member of Women's Care of Wisconsin.