Cranial Technologies

As the owner of the requested photo and/or video, I hereby consent and release my participation and/or the participation of my child and permit Cranial Technologies Inc:

• Use of photos and/or video footage for education, training and promotion of Cranial Technologies products and services.

• To adjust the length or size of and/or remove any watermarks from the original video(s) to comply with marketing standards and advertising platform video format requirements.

I understand that the photos and/or video, or some portion thereof, may be protected by state law and/or HIPAA. I further understand that, because the photos or videos may be disclosed to an entity or individual that is not a health care provider or health plan covered by HIPAA, the photos and/or video may be re-disclosed. I release and discharge Cranial Technologies, Inc. and all parties acting under their license from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photos and/or video.

I understand that I may revoke this authorization at any time by notifying Cranial Technologies, Inc. in writing. However, if I choose to do so, I understand that my revocation will not affect any publication or actions taken by Cranial Technologies, Inc. before receiving my revocation.

I understand that this authorization remains effective until revoked by the participant, parent or authorized representative.

Cranial Technologies, Inc. • (844) 447-5894 • F502 Rev00 ECO23-096 Effective Date: 06/06/2023