I hereby authorize Doctor Matrix Medical Group, P.A. (“Doctor Matrix”) to use and disclose my image, video recording, audio recording, personal testimony, name, contact information (such as phone number, e-mail address, and address), demographic information, and health condition and related health information for the following purposes:

To Market Doctor Matrix’s Products/Services: To market Doctor Matrix’s products and services to me. For example, Doctor Matrix may use my e-mail address to tell me about new products or services available from Doctor Matrix.

For Doctor Matrix’s Promotional Purposes: In blogs, articles, films, videotapes, books, portfolios, presentations, marketing materials and similar documents for Doctor Matrix’s marketing, promotion and advertising activities.

To Market A Third Party’s Products/Services: To market a third party’s products and services to me. For example, Doctor Matrix may use my e-mail address to tell me about a pharmaceutical company’s products. I understand Doctor Matrix may receive remuneration from the third party for making these communications.

I understand that I have the right to revoke this Marketing Authorization, in writing, at any time by sending such written notification to Doctor Matrix, 7033 E Greenway Parkway Suite 310, Scottsdale, AZ, 85254 except to the extent that action has been taken in reliance upon my Authorization. I understand that information used or disclosed pursuant to this Marketing Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by Federal or State law. Doctor Matrix will not condition my treatment, payment, enrollment or eligibility for benefits on whether I provide authorization for the requested use or disclosure.

I understand that I have the right to: inspect or copy the health information to be used or disclosed as permitted under Federal or State law; refuse to sign this Marketing Authorization; and receive a copy of this Marketing Authorization.

This Marketing Authorization expires five years from the date of my signature below, unless I revoke this Marketing Authorization at any earlier time.

I have read the above information and authorize Doctor Matrix to use and disclose the identified information for the purposes described herein.

By checking the box next to “I agree to UpScript’s Marketing Authorization” at registration, you acknowledge that you have read and agree to the terms of the Doctor Matrix Marketing Authorization.