By submitting this form, I authorize Progressive Orthotics & Prosthetics ("Progressive O&P") to use the photos and/or videos I have provided, along with any story or comments I have submitted, for educational and promotional purposes. This includes the Progressive O&P website, social media accounts, printed materials, and presentations.

I understand that:

• This authorization is voluntary. My treatment, payment, or eligibility for care will not be affected if I choose not to submit or sign.
• My submission may reveal that I am a patient of Progressive O&P and may show my orthotic or prosthetic device.
• Progressive O&P will identify me only as I have selected above.
• Progressive O&P may choose not to use any submission and may edit or crop images and videos for length and format.
• I will not receive payment or compensation for this use.
• Once information is posted publicly, it may be viewed, shared, or copied by others, and it may no longer be protected by federal privacy laws.
• I may revoke this authorization at any time by sending written notice to Progressive O&P at 1111 Willis Ave., Albertson, NY 11507 or info@progoandp.com. Revocation will not affect any use made before the notice was received, but Progressive O&P will remove content from its own website and social media accounts within a reasonable time.
• This authorization remains in effect until five (5) years from the date signed.
• I am entitled to a copy of this signed authorization upon request.

I confirm that I am the person shown in the submitted media, or that I am the parent or legal guardian of the person shown, and that I have the right to provide this authorization. If others appear in the photos or videos, I confirm that they have agreed to be included.