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Testimonial Authorization: *

I hereby authorize and consent to the use and disclosure by Bock Integrative Medicine (BIM) of the testimonial I submit via this “Share Your Story” website, email, or by other means to BIM, for marketing and promotional purposes in any digital and print format. I understand that my first or full name, as I indicate below, written endorsement, and experience with BIM will be publicly distributed on this site and/or in other media. This consent is freely given in exchange for services already received and is binding without further compensation. I understand that I may revoke this consent at any time, except that such revocation will not act retroactively against materials in non-virtual media, such as print, but such material shall be removed from virtual media within a reasonable time. BIM reserves the right to edit testimonials for space, grammar, or appropriateness and is not obligated to publish. I hereby waive and release any and all claims against Kenneth Bock, M.D., BIM, its principals, employees, agents and assigns, from any and all damages for invasion of privacy, portrayal in false light, defamation, or for any other cause of action, whether civil, criminal, or administrative, for use consistent with the permission herein granted.

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