Client Digital Signature Usage Authorization

Dax J. Lonetto, Sr., PLLC uses Arctrieval's service to request and manage documents, records and evidence related to your case or claim. By signing below, I understand, agree to and authorize the following:

1. Arctrieval's Privacy Policy and Terms of Use which may be reviewed at www.Arctrieval.com.

2.Dax J. Lonetto, Sr., PLLC and Arctrieval Inc. to use my personally identifiable information, government issued identification and a digital image of my signature to obtain any and all information related to my case or claim.

3. Dax J. Lonetto, Sr., PLLC and Arctrieval Inc. to affix a digital image of my signature to documents necessary to obtain information related to my claim or case.

4. Information related to my case or claim may include, but is not limited to: protected health information, medical records, billing records, medical images, accident reports, repair estimates, witness statements, insurance claim information, etc

5. My authorization and this agreement are voluntary and I may refuse to sign this form.

6. I may revoke this agreement and my authorization at any time, in writing by submitting a written revocation to:

Dax J. Lonetto, Sr., PLLC 18715 N. Dale Mabry Hwy., Lutz, Florida 33548

Arctrieval Inc. 23233 N. Pima Road, Suite 113 PMB 145 Scottsdale, AZ 85262

7. My revocation will take effect upon receipt, except to the extent others have already acted in reliance upon this agreement and my authorization.

8. Unless, I revoke this agreement and my authorization earlier, it will expire 24 months from the date shown below.

Client Signature: Please sign clearly and as large as possible within the lines in the

area to the right. Do not sign on, touching, or outside the lines.

Arctrieval, Inc. Confidentiality Notice: This communication, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information Any unauthorized review, use, disclosure or distribution of this information is prohibited. If this was sent to you in error, please notify the sender and destroy all copies of the original message.