Testimonial Consent Form

Patient Testimonial Release Consent

Purpose

By acknowledging this release, I am authorizing MSB Holdings, Inc., dba “Rugiet” (hereinafter referred to as “Rugiet” to use and disclose my oral, written and/or video testimonial (the “Testimonial” or “Content”) for purposes of publicizing Rugiet’s services and products and for marketing and public relations efforts. I hereby acknowledge and agree that the Testimonial may be used in printed publications (including case studies), multimedia presentations, on websites, or in any other distribution media and that my Testimonial may be distributed to the public.

By acknowledging this form, I consent to Rugiet's use and disclosure of the information in my Testimonial and acknowledge that my Testimonial may be distributed to the public and, once public, cannot be retrieved.

Expiration: This authorization expires three (3) years after the date I acknowledge it, or on the date Rugiet receives my written revocation, whichever occurs first.

Right to Revoke: You have the right to revoke this Release at any time by providing written notice of your revocation and submitting it to Rugiet, Attention: Marketing Director,310 Comal St., Austin, TX 78702. Revocation is effective when Rugiet receives it. Revocation will not affect any use or disclosure Rugiet made in reliance on this Release before receiving it; however, upon revocation Rugiet will stop all further use and disclosure of the Testimonial, will remove the Testimonial from channels Rugiet controls within thirty (30) days, and will use commercially reasonable efforts to request removal from channels Rugiet does not control.

CONSENT TO RELEASE

I hereby authorize Rugiet, and the healthcare providers, staff, and service providers acting on its behalf, to use and disclose the following protected health information about me in Rugiet's marketing, media, and public relations efforts: my name, image, likeness, and voice; the fact that I am or have been a Rugiet patient; the condition(s) for which I sought treatment from Rugiet; the Rugiet products or medications prescribed to me; and my statements about my treatment and results, together with any other information I choose to include in the Testimonial. I understand that publication of the Testimonial will identify me publicly as a Rugiet patient treated for the condition(s) I describe, and that no other protected health information from my medical record will be used or disclosed under this authorization. I understand and approve the disclosure of the information described above to the following recipients: Rugiet's marketing, advertising, and public relations agencies and contractors; print, broadcast, and online news and trade media; Rugiet's own websites, emails, and printed materials; and the social media and digital advertising platforms identified here: Facebook Instagram, Twitter, YouTube, TikTok, Pinterest, and LinkedIn or other social media pages

I understand that I am providing the testimonial information to Rugiet and that, apart from the information described above, neither Rugiet nor my treating healthcare provider will use or disclose to the media or the public any protected health information in my medical records, the confidentiality of which is protected by federal and state statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and the Texas Medical Records Privacy Act., I release Rugiet from claims for damages based on Rugiet's use of the Testimonial as authorized by this Release, except that nothing in this Release waives any claim arising from a use or disclosure of my protected health information in violation of this Release or applicable privacy law, or my right to file a complaint with the U.S. Department of Health and Human Services or the Texas Attorney General.

I further acknowledge that my testimonial shall not include any person or personally identifiable information about anyone else other than me unless I receive written approval from Rugiet and the persons at issue acknowledge a release provided by Rugiet.

I further acknowledge that (i) I am not required to acknowledge in order to receive treatment or payment for my care; (ii) Information used or disclosed under this authorization may be reused by the recipient and may no longer be protected by privacy regulations; (iii) I may revoke this authorization at any time as described in the Right to Revoke section above, and the revocation will be effective on the date notified (except to the extent action or publication has already been taken based on my earlier authorization, in which case we will utilize commercially reasonable efforts to attempt to remove the assets from our system but cannot recall uses outside our control); (iv) I understand that any protected health information or other information released via the social media or digital advertising platforms identified in this Release may be subject to redisclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.

By acknowledging below, I agree and acknowledge that I have read and understood the above Release and agree to all terms described. I am of legal age and freely acknowledge this Consent to Release my Patient Testimonial or other media I provided to Rugiet.

Payment

I acknowledge and agree that Rugiet will credit my Rugiet account $150 for participating, on the terms described below. I acknowledge and agree that this credit shall be the sole and entire compensation I receive and no other compensation of any kind shall be due upon termination of this Agreement or thereafter. I will receive the credit so long as I demonstrate a reasonable, good-faith effort to complete the testimonial process, regardless of whether Rugiet ultimately uses the Content. The credit may be withheld only if I do not demonstrate a reasonable effort to complete the testimonial. I understand that Rugiet will disclose, in or alongside any published Testimonial, that I received compensation in exchange for it.

Representations/Indemnity

I represent and warrant to Rugiet that (i) I am at least eighteen (18) years old, (ii) I have the power and authority to enter into this Agreement on behalf of myself and to perform its obligations; and (iii) the Testimonial or any related materials will not violate the rights of any third party. I hereby indemnify and hold harmless Rugiet from any damage or cost (including reasonable attorneys’ fees) arising out of my breach of the representations in this section, provided that I have no obligation to indemnify Rugiet for any claim arising from Rugiet's own use, disclosure, or safeguarding of my protected health information.

Miscellaneous

This Release shall be construed by the laws of the State of Texas. If any part of this Release is found to be invalid, such invalidity shall not affect the remainder of this Release.

I have read the authorization and release information and give my consent for the use as indicated above. I acknowledge that I will receive a copy of this authorization that reflects my acknowledgment, and that I may request an additional copy at any time from Rugiet, Attention: Marketing Director, 310 Comal St., Austin, TX 78702.