I,   First Name   Last Name   , (Patient Name) hereby authorize Premier Surgical Associates, LLC, to use certain protected health information (PHI) about me. Specifically, this authorization permits you to use the following PHI about me:

• Name, age, description of medical condition and treatment, photo and/or video image

The information in this authorization is to be used or disclosed for the following purpose:

• Patient testimonial article and/or video
• Patient before & after results on Practice website, social media, and advertisements

I understand that my information may not be protected from re-disclosure one it has been released pursuant to this authorization.

I understand that my treatment will not be conditioned on signing this authorization.

I understand I have the right to revoke this authorization by written notification to Premier Surgical Associates, PLLC, to which this authorization is submitted. Premier Surgical will comply except to the extent that the provider has already acted in reliance upon this authorization.

This authorization will expire 10 years from enacted date.