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We are excited to hear about your experience with Kremer Eye Center and hope you will share your story with us to encourage others to make this life changing decision! You will also get the chance to be featured on our website or social media pages!!

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Kremer Eye Center and/or its affiliates (“Company”) intend to engage in certain marketing/public relations activities regarding vision correction procedures, including a procedure called LASIK (laser assisted in situ keratomileusis), cataract surgery, etc., for the purpose of generating interest in vision correction procedures as well as for other purposes of the Company.

By submitting this release form, you agree to allow the Company to use your name, likeness, photo, video, and/or quotations in print, radio, internet, social media, or other marketing/public relations materials regarding your vision correction experiences.

By signing below you:

  • Authorize the Company to use your name, identity, image, persona, photographs, video, likeness, voice, spoken or written words, or abstracts thereof, or any other reproduction or representation of you (collectively, your “Persona”), as well as your medical information in marketing/public relations, patient education and other promotional activities of the Company.
  • Acknowledge that the Company may edit or remove some portion of your written words, or use an abstract thereof, but will not change the overall sentiment.
  • Acknowledge that the marketing/public relations activities may cause your Persona and medical information to be disclosed to prospective patients of the Company and to the general public.
  • Release the Company, its agents and employees from any liability or damages
  • Acknowledge that you are signing this Authorization voluntarily without payment or compensation, in good faith, without duress or pressure of any kind and without reliance on any representations made by the Company or anyone representing the Company.
  • Represent that the information you provide regarding your vision correction experiences is true and not misleading.
  • Acknowledge that you have been informed that you do not have to sign this Authorization and that your treatment will not be denied if you do not sign this Authorization.

Understand that themarketing/public relations activities may limit Federal and/or state privacy law protection, if any, of your Persona and/or medical information due to the nature of those activities.

You may revoke this Authorization at any time by submitting a notice in writing to TLC, Attn: General Counsel, at 16305 Swingley Ridge Road, Suite 300, Chesterfield, MO 63017 except to the extent action has already been taken in reliance on this Authorization.

Unless revoked, this Authorization will expire on December 13, 2019.

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