BalanceWear Survey

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Please give us a background of your diagnosis and what does it feel like to you.* This field is required.
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How did you hear about BalanceWear?* This field is required.
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What was your BalanceWear fitting session like? What was your initial reaction to BalanceWear?* This field is required.
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How long have you been using BalanceWear and wow often do you wear it?* This field is required.
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How has BalanceWear affected the quality of your life? How has it changed the way you think about your condition and your abilities?* This field is required.
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What advice would you give to people who are wondering if BalanceWear might be right for them?* This field is required.
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How would you rate BalanceWear Vest?
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Thank you for answering our survey!

On the next page, please fill out your contact information
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Name* This field is required.
First Name
Last Name
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Email
example@example.com
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Phone Number
Please enter a valid phone number.
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Motion Therapeutics Inc. Publicity Release I understand, acknowledge and hereby grant to MOTION THERAPEUTICS, INC., and those acting with their authority and permission, and their respective successors and assigns (collectively “Releasees”), the absolute right and permission to interview, photograph, film and record my appearance, image, likeness and voice in photographic, audio, video, digital or other forms (“Media”), including the right to use the same and my biographical information, including any individually identifiable health information as that term may be used in regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), in whole or in part, in perpetuity, in and in connection with Releasees’ publicity, marketing, commercial or promotional materials. I hereby waive any right to inspect or approve: (a) the finished Media; (b) any printed matter that may be used in conjunction with the Media; or (c) the eventual use to which the Media may be applied. I hereby release, discharge, waive and agree to save harmless Releasees from any liability, loss or damage, whether or not caused by the negligence of releasees, caused by, resulting from, arising out of or in connection with the use of my image, likeness, voice, biographical information and individually identifiable health information in accordance with the terms hereof, including from claims that Releasees’ use and/or disclosure of the same is libelous, defamatory, invades privacy or publicity rights, infringes or otherwise misappropriates intellectual property rights or infringes upon HIPAA rights or rights of publicity of me or any other person, or is a misrepresentation of me or my person. I acknowledge and agree that Releasees are and will be the sole owner of all rights in and to the Media, and the recordings thereof, for all purposes, including but not limited to all copyrights. I grant the Releasees the right to use all or any portion of the Media now or in the future, in any media now known or later devised, including television, radio, internet, cable, pay-per-view broadcasts, electronically or digitally in any format, streaming, podcasting, for broadcasting or other distribution, including without limitation for commercial sale and distribution or as a tie-in with another product or service, or in any promotional capacity determined by the Releasees or for any other purposes. I hereby assign to the Releasees whatever rights or interest I may have or ever have in the Media by virtue of my appearance thereon or for any other reason. I shall have no right to receive or demand from the Releasees or its parent companies or affiliates any compensation in connection with the Media. I have read the above authorization and release prior to its execution, and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns. I am over 18 years of age and have the right to make this agreement. Please sign below if you agree to this Publicity Release. If you decide not to, we will not publish your answer to this survey but you can still submit it.
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