Testimonial

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Surgery Performed and/or Medical Condition currently being treated for

Please describe your experience with Sacramento Eye Consultants, your surgery, or your vision

I hereby authorize Sacramento Eye Consultants and staff to copy, exhibit, publish or distribute my feedback for purposes of publicizing Sacramento Eye Consultants’ services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I authorize Sacramento Eye Consultants to include my first name and last initial in association with this testimonial.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears.

I hereby hold harmless and release Sacramento Eye Consultants from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

You have the right to revoke this Release at any time by providing written notice. Please understand that revocation of this Release will not affect any action Sacramento Eye Consultants took in reliance on this Release before receiving your revocation.

I authorize the release of information pertaining to diagnosis and/or treatment.I do not authorize the release of information pertaining to diagnosis and/or treatment

I authorize the use of my first name and last initial in conjunction with my testimonialI do not authorize the use of my first name and last initial in conjunction with my testimonial

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