Release
Dear Pet Owner,
Please accept our deepest sympathy for the emergency medical situation with your pet. Please be comforted that if you are reading this, as of this writing, the hospital you are in is one of only a small group of veterinary hospitals in the country to offer hemoperfusion / hemodialysis, and you are in the best of care. Our company is proud to manufacture the device that is used to filter life threatening toxins directly from circulating blood. Our team members are also pet owners and animal lovers and we wish you comfort in this stressful time.
With this form we are requesting your permission to use photographs, videos, and treatment data collected during your pet’s treatment in our outreach efforts to other veterinary hospitals and doctors. It is our goal to make this life saving technology available to more veterinary doctors and pet owners across the country and around the world, and your help in this effort is greatly appreciated.
Respectfully,
Ronald L. Shape
Dr. Ronald L. Shape,
CEO, ImmutriX Therapeutics, Inc., dba. AimaLojic Animal Health
AM-FORM 1000-00 REV 0 Release
For good and valuable consideration, the receipt and sufficiency of which is hereby
acknowledged, I, the undersigned, agree as follows:
1. I agree to allow my pet to be photographed, recorded, and videotaped and
content shared with ImmutriX Therapeutics, Inc., dba AimaLojic Animal Health
(“Company”) in connection with the medical treatment performed on my pet.
2. I hereby irrevocably authorize Company and its affiliates to copyright, publish,
reproduce, exhibit, transmit, broadcast, televise, digitize, display, otherwise use,
and permit others to use, (a) my name, image, likeness, and voice, and (b) all
photographs, recordings, videotapes, audiovisual materials, treatment data,
writings, statements, and quotations of or by myself (collectively, the
“Materials”), in any manner, form, or format whatsoever now or hereinafter
created, including on the Internet, and for any purpose, including, but not
limited to outreach efforts, educational content, advertising or promotion of
Company, its affiliates, or their services, without further consent from or
payment to me.
3. It is understood that all of the Materials, and all films, audiotapes, videotapes,
reproductions, media, plates, negatives, photocopies, and electronic and digital
copies of the Materials, are the sole property of Company. I agree not to
contest the rights or authority granted to Company hereunder. I hereby forever
release and discharge Company, its employees, licensees, agents, successors,
and assigns from any claims, actions, damages, liabilities, costs, or demands
whatsoever arising by reason of defamation, invasion of privacy, right of
publicity, copyright infringement, or any other personal or property rights from
or related to any use of the Materials. I understand that Company is under no
obligation to use the Materials.
4. This document contains the entire agreement between the Company and the
undersigned concerning the subject matter hereof.
AM-FORM 1000-00 REV 0 Release
