The Wahls Protocol Consent & Release Form
By filling out and submitting the form below I, hereby irrevocably and perpetually grant to Dr. Terry Wahls LLC. its subsidiaries, affiliates, successors and assigns:
That I consent to be featured in a case report and agreed to be identified by initials and relevant clinical details in the case report. We should either add that statement to the release or create a separate document that is in addition to the release and includes this statement.
The right to photograph, videotape and record my name, voice, appearance, likeness, and/or written testimony along with any material furnished by me, in whole or in part, in any of Dr. Terry Wahls LLC.’s books, program materials, marketing materials and programs.
The right to use my written, oral and video submissions in any fashion Dr. Terry Wahls LLC. uses, in its discretion.
The right to publish, exhibit and distribute the use of my name, voice, appearance, testimonial and/or likeness along with any material furnished by me, in whole or in part, worldwide, for any commercial purpose, including but not limited to the advertising or solicitation of business, by any means of mass and/or electronic media, including but not limited to print, radio, television and promotional materials, events and/or marketing plans.
I understand Dr. Terry Wahls LLC. is relying on this authorization and Release by interviewing and photographing, taping or recording my appearance and that my authorization and this Release is irrevocable and may not be withdrawn. I waive any right to inspect any materials of any time prior to release, use or publication, and, on behalf of my heirs, executors and assigns, I waive any claims that I may have against Dr. Terry Wahls LLC., its representatives, its publisher, and their licensees, successors and assigns, based upon such use, including without limitation any claims with respect to defamation, rights of privacy and publicity and copyright
I hereby acknowledge that I have not been paid or otherwise compensated, and I further certify that all material, whether verbal, written or exhibited by me has not been scripted and represents my individual opinions and beliefs, and is true and correct to the best of my knowledge.