Name *

First Name

Last Name

Testimonial Consent *

I authorize Neu Medical to use my testimonial and information herein in its public relations efforts.

I understand that I am providing the testimonial information to Neu Medical.

OptionI agree that I will make no monetary or other claim against Neu Medical for the use of my statements. 3

I understand that my treating healthcare provider (if applicable) will not be providing any protected information to the media or the public, including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulation, including the Health Insurance Portability and Accountability Act (HIPAA).