Share your Success Story with Dr Kuri

I, hereby give permission to Dr. Pedro Kuri (hereinafter, “Doctor”) to photograph the Patient and use such photographs, or those submitted by the Patient, and testimonials written by the Patient in all forms of media, for any and all promotional purposes including, but not limited to, advertising, publicity, display, audiovisual, exhibition, commercial or editorial use. The Patient hereby understands and agrees that the term “photograph” as used herein encompasses still photographs, audio recording, motion picture footage and video. The Patient hereby further consents to the reproduction and/or authorization by the Doctor to reproduce and use such photographs and testimonials for use in all domestic and foreign markets. The Patient hereby forever releases the Doctor and any of the Doctor’s associates, affiliates, appointed advertising agencies and designated directors, officers, agents, employees and patients from any and all claims that arise or could arise from the use of the Patient’s photograph and testimonial as stated herein above.