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I am at least 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

Testimonial Release Form

I hereby grant Park Avenue Chiropractic, Inc. to use my testimonial in any and all of its publications, including website entries, without payment or any other consideration.

I understand and agree that these materials will become property of Park Avenue Chiropractic, Inc. and will not be returned.

I hereby authorize Park Avenue Chiropractic, Inc. to exhibit, publish or distribute this testimonial for purposes of publicizing Park Avenue Chiropractic, Inc. or for any other lawful purpose.

I hereby hold harmless and release and forever discharge Park Avenue Chiropractic, Inc. 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.