Intended Use (but not limited to) I agree to allow PearlmanMDs to interview, video record, and/or photograph me. I understand that PearlmanMDs may use my name, my image, and/or my spoken or written comments for promotional and/or educational uses. I understand that these promotional/educational uses may include feature stories, advertisements, videos, or other formats that will appear in public media. I agree to allow PearlmanMDs to use my name, comments, and/or image for an indefinite period of time without additional approval, but that I may contact PearlmanMDs at any time to remove the content. I understand that my health care and payment of my health care will not be affected if I do not sign this form. I understand that once this information is disclosed, it may no longer be protected by federal privacy regulations. I understand that this authorization is voluntary and that I may revoke this authorization at any time by sending an electronic message to in**@pe*********.com