RELEASE FORM

Patient's Name:

Patient's Date of Birth:

MEDIA RELEASE

I, the undersigned, grant FriskaAi, its affiliates, and its representatives ("FriskaAi") the right to use, reproduce, distribute, and display photographs, videos, or recordings (collectively, "Media") of me, taken or recorded on at

RIGHTS GRANTED

I grant FriskaAi the non-exclusive, perpetual, worldwide right to:

Use the Media for any purpose, including promotional, advertising, educational, or commercial purposes
Edit, modify, or alter the Media as FriskaAi sees fit.
Use my name, likeness, and voice in connection with the Media

RELEASE

I release FriskaAi from any liability for:

Use of the Media as authorized above.
Any claims, demands, or causes of action I may have for libel, slander, invasion of privacy, or other torts.

CONFIDENTIALITY

I understand that FriskaAi may use the Media in a manner that may involve confidential or sensitive information. I agree to maintain confidentiality and not disclose any sensitive information.

CERTIFICATION

I certify that:

1. I am at least 18 years old (or have parental/guardian consent).

2. I have read and understand this Release Form.

3. I sign this Release Form voluntarily.

SIGNATURE

Signature:

Date:

PARENT/GUARDIAN CONSENT (IF APPLICABLE)

If the patient is under 18, please complete:

Parent/Guardian Name:

Parent/Guardian Signature:

Date: