I do hereby authorize Magnolia Eye Care, its agents, successors, assigns, subareas, subsidiaries and/or affiliates to use my photo and first name to said organization by me for advertising used to promote the Magnolia Eye Care practice.

I agree that I am donating this information and will not be compensated. I do not expect to approve the layout or design of said information.

I agree that there is no cost to me and will be no cost to the organization for publishing this material.

I hereby warrant that I have not given any organization or entity the exclusive right to use my work or my name in any way that would affect this agreement.