Media Release Form

Step 1 of 2

First Name *

Last Name *

Practice Name or Office Number *

Email *

Job Title *

Allowed Platforms for Media: *

I am 20 years of age or older and I am competent to contract in my own name and on behalf of the organization I am representing. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. Please submit questions to: marketing@medi-ehr.com

I grant permission to Medi-EHR,LLC hereinafter known as the “Media” to use my quote/testimonial, company name and logo on the Medi-EHR website (per the example below) and for use in Media publications (mentioned above):

Electronically Signed by: *

Date *

Comment