Integrative Wisdom Release

By submitting this form, I hereby acknowledge that I am at least 18 years of age. I authorize Integrative Therapeutics, LLC (“Integrative”) to use any and all reproductions of materials submitted including my image, voice, condition, or personal testimony, whether written or audio/visual. Any creative services provided to Integrative remain the property, solely and completely of Integrative, to be used exclusively for the promotion of Integrative and its family of services without compensation or royalties to me.

I authorize Integrative to edit any content or materials I may submit through this form as it deems necessary. I acknowledge that it is at Integrative’s discretion to post materials received and that my content may or may not be shown publicly.

I understand that my creative services may be used and shared with local, state, and national media outlets, including newspapers, magazines, television broadcast stations, radio stations, internet, and social media sites. I understand that media representatives are not covered by federal privacy regulations and my health information, if given in my creative services, may be disclosed and no longer protected by these regulations.

I agree that any content submitted through this form does not contain any material that may deemed unlawful. Furthermore, I agree that no material submitted is protected under copyright.

I understand that by submitting the form below I am voiding any previous elections to “opt out” of releasing my health information (if provided) for the express purpose(s) outlined below, including:

  • All photography, video, audio, and/or printed testimonial;
  • Information about my specific injuries or medical condition (if shared in the provided material);
  • My prognosis (if shared in the provided material);
  • My age (if shared in the provided material); and
  • My city, county or state of residence (if shared in the provided material)

Finally, I do understand that I may revoke this authorization at any time, provided that I do so in writing. I understand that information and content released between the effective date of this authorization and the date of the revocation may still be used in the public domain.