VIDEO/PHOTO AND INTERVIEW CONSENT AND RELEASE FORM

I, patient, hereby authorizes Bobby Nourani, Bobby Nourani, D.O. Medical Corporation, and Slanted Adaptor LLC, the right and permission to copyright and/or publish, reproduce, or otherwise use my name, voice, and likeness in video, photographs, written materials, and audio-visual recordings. I acknowledge and understand these materials about or of me may be used for both commercial and/or non-commercial purposes, including but not limited to social media and the internet. The rights granted herein to use the Subject's Likeness and the Subject's Story shall extend to any reproductions in color or otherwise, made through any medium and in any and all media now or hereafter known whether used singularly or in conjunction with printed and/or other accompanying material and whether used for any purpose whatsoever, including commercial purposes and regardless of the manner in which said use is transmitted (e.g., television broadcast, electronic or digital media, printed material, newsprint, brochures, all printed collateral, motion pictures and video

I understand that my image may be edited, copied, exhibited, published and/or distributed. I also understand this material may be used individually or in conjunction with other media in any medium, including without limitation to print publications, digital publications, and/or public broadcast for any lawful purpose. There is no time limit on the validity of this release nor are there any geographic limitations on where these materials may be distributed. I hereby acknowledge and grant Bobby Nourani, Bobby Nourani, D.O. Medical Corporation, Slanted Adaptor LLC, and its employees, agents, licenses, successors, and third-party organizations all ownership rights and irrevocable right and permission to use, copyright, publish, sell, distribute, and/or promote the recorded video, photo, interview, and/or audio.

understand that my participation is voluntary and that I may, at any time, discontinue my involvement before signing this document. If I choose to discontinue participation, I will notify the principal parties Bobby Nourani, Bobby Nourani, D.O. Medical Corporation, Slanted Adaptor LLC, & any other parties involved by providing written notice. I understand that Bobby Nourani, Bobby Nourani, D.O. Medical Corporation, and Slanted Adaptor LLC, can see no risk presently and that I take full responsibility for my involvement in this project and the risks that it may entail (be they legal, physical, or mental) and release Bobby Nourani, Bobby Nourani, D.O. Medical Corporation, and Slanted Adaptor LLC, from any claims, demands, losses, damages, suits, and liabilities of any kind whatsoever in connection with the foregoing. I hereby certify that I am over eighteen years of age and am competent to contract in my own name insofar as the above is concerned. If I am under eighteen years of age, my parents or legal guardians have read this document and have given their consent by signing below. By signing this form, I acknowledge that I have completely read and fully understand the above consent and release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for marketing, educational, promotional, and/or any other lawful purpose whatsoever.