I authorize Mountain Land Physical Therapy Partners and its subsidiaries to use my image and likeness in various mediums, including but not limited to print publications, online publications, presentations, websites, television, social media, and other marketing and educational purposes. This authorization remains in effect until I, or my guardian, submit a request for its revocation. I acknowledge and agree that no royalty, fee, or other form of compensation will be payable to me for the use of this media.

I understand that my likeness displayed may inherently constitute protected health information (PHI).

This authorization will remain in effect indefinitely unless termination is requested in writing.