Patient Authorization Form (3 Selections)

Patient Marketing Authorization Form

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By completing this Patient Authorization Form (“Authorization”), you are giving permission to Mainstay Medical Limited, including its employees, agents, or representatives (“Mainstay”) and/or your health care provider (“Provider”), to utilize or share your personally identifiable data and content regarding your experiences and progress with the ReActiv8® Neurostimulation System (“ReActiv8”) through videos, photographs, and/or written statements (“Recorded Content”). The Recorded Content will include your likeness, image, and/or voice, and will be recorded by Mainstay through a contracted agency or possibly with a Mainstay representative’s smartphone. Please only select the authorizations (by inserting checkmarks or your initials in the boxes) you agree to, and do not hesitate to contact your Mainstay representative with any questions.

1) Updates to Your Physician / Health Care Provider (“Provider”)

By checking this box, you authorize Mainstay to share your Recorded Content with your Provider for purposes of informing them about your ReActiv8 progress, feedback, and updates. This can help your Provider better understand and manage your ReActiv8 therapy and your overall care. Please note that the Recorded Content may be sent to your Provider via upload to a secure site accessible by your Provider, or through a Mainstay smartphone’s email or texting app (which may not utilize encryption or similar security measures).

2) Use of Recorded Content by Your Provider

By checking this box, you authorize your Provider to share or publicize your Recorded Content through the Provider’s website, social media accounts (such as LinkedIn or Facebook), or other educational/marketing platforms whether electronic or hardcopy. Among other things, your Recorded Content may be used to educate the public about ReActiv8 therapy, including prospective patients and their family members, and represent your Provider as a certified ReActiv8 clinician. If you agree, please identify your Provider:

Provider or Practice Name

3) Mainstay Marketing & Educational Purposes

By checking this box, you authorize Mainstay to use your Recorded Content for product education, public awareness, marketing, training, and/or related purposes in the US and internationally, to help inform the public, health care providers, and potential patients about ReActiv8. As examples, your Recorded Content may be used in publications, Mainstay website(s), articles, marketing materials, or educational materials. The Recorded Content will become the property of Mainstay and you agree to assign full copyright of all manifestations of the Recorded Content to Mainstay together with the right of reproduction.

Your Recorded Content will not be used in any inaccurate, inappropriate, or misleading manner. Mainstay will not sell your Recorded Content to any other party without your permission. You agree to only showcase or perform what you are physically comfortable with regarding body movements or activities in your Recorded Content, and release Mainstay from any liability or harm that may result from the Recorded Content. You understand that Mainstay is a medical device manufacturer and cannot review your Recorded Content for any clinical issues or concerns. Please contact your Provider with any questions, issues or concerns (and, of course, call 911 in case of any emergency situation).

I have read the above and agree to this Authorization. This Authorization will be effective for a period of five (5) years, although you may rescind this Authorization at any time by providing Mainstay with written notice. You understand that you will not receive any compensation for this Authorization. Your agreement to share Recorded Content is completely voluntary, and you may refuse to sign this Authorization without any penalty or negative impact to your health benefits or ReActiv8 therapy.

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