VIDEO AND/OR PHOTO RELEASE AUTHORIZATION I do hereby consent and agree that Complete Women Care, GYN Emergent Care Center, and the GYN Surgical Institute, its employees, or agents have the right to use the video materials that I will upload via this form, in any and all media, now or hereafter known. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to Complete Women Care, GYN Emergent Care Center, and the GYN Surgical Institute, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I also understand that Complete Women Care, GYN Emergent Care Center and the GYN Surgical Institute is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result. I represent that I am at least 18 years of age, have read and understood the foregoing statement, and am competent to execute this agreement.

Please only click SUBMIT once and allow your video to upload. Your video will be uploading and will proceed to the submission successful page once it is complete. You can view your upload percentage in the bottom left corner of your browser.