Physician Testimonial Release Form

EvoEndo, a Delaware corporation, having a place of business at 12649 East Caley Avenue, Suite 116, Centennial, CO  80111 (“EvoEndo”) desires to take, make, create, accept, record, obtain, and/or copy one or more images, likenesses, photographs, video recordings, sound recordings, testimonials, personal accounts, quotations, or other statements of or relating to the undersigned (collectively, “Works”) and to use, copy, reproduce, edit, modify, adapt, distribute, publish, display, exhibit, exploit, broadcast, disseminate, and otherwise use the Works anywhere in the world in any lawful manner, including, but not limited to, using such Works in advertisements, brochures, public presentations, websites, emails, or otherwise in connection with the promotion of EvoEndo’s business or reputation, which shall be distributed or broadcast within EvoEndo or to the public, and to also include therein certain text or audio dialogue concerning the undersigned and other matters of concern to EvoEndo;

Whereas I am willing to have the Works taken, made, created, accepted, recorded, obtained, used, copied, reproduced, edited, modified, adapted, distributed, published, displayed, exhibited, exploited, broadcasted, disseminated, and otherwise used anywhere in the world in the above manner;

Now therefore, for the consideration of goodwill and publicity that I may receive relating to the publication, distribution, or other use of the Works and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I agree as follows:

I grant to EvoEndo the following rights:

a) To take, make, create, accept, record, obtain, and/or copy recorded Works as more specifically described above;

b) To accept, take, record, edit, make, create, publish, or obtain written Works as more specifically described above; and

c) To use, copy, reproduce, edit, modify, adapt, distribute, publish, display, exhibit, exploit, broadcast, disseminate, and otherwise use, either in whole or in part, such Works in whatsoever manner EvoEndo desires anywhere in the world, including, but not limited to, in advertisements, brochures, presentations, websites (including social media sites such as Facebook and YouTube), film, video, or multimedia productions, printed and written material, any educational, marketing, and promotional materials or otherwise in connection with the promotion of EvoEndo’s business or reputation.

I hereby release and discharge EvoEndo, its employees, agents, successors, licensees, and assigns from any and all claims I might have in connection with any activity associated with paragraphs (a), (b), and (c) above, including, but not limited to, any claims for defamation; violation of any moral or artist rights; any right of privacy or publicity; and/or any copyright or trademark.

I further acknowledge that I will receive no compensation from EvoEndo for any use of the Works except as explicitly stated herein.

I acknowledge that EvoEndo is the sole and exclusive owner of all rights, title, and interest in all copyrights, trademark rights, and any and all other intellectual property rights, worldwide, in the Works and the individual components thereof and I shall take no action to challenge or object to the validity of such rights or EvoEndo’s ownership or registration thereof.  I also agree to execute any documents deemed appropriate by EvoEndo to perfect EvoEndo’s right and title in such Works or rights associated therewith.

This document represents the entire agreement between EvoEndo and me with respect to this subject matter.  This agreement and all actions related to it shall be governed by the laws of the State of Colorado.

I represent, warrant, and agree that I have read and understand the contents of this Release.