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.
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.