Please read the information below carefully, and ask if you have questions about this form or its uses. If you choose not to sign this form, your decision will have no effect on your medical care, payment for your care, or the health benefits you receive.

Tivity Health, Inc. respects the privacy of your information. Tivity Health, Inc. requests your consent to use your story for purposes not related to your medical treatment or care.

I hereby give Tivity Health, Inc., its assigns, licensees, and legal representative the irrevocable right to use my photos, verbal statements, taped statements, or written correspondence in whole or in part, in all forms of media and in all manners, including advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished product, including written copy, that may be created in connection therewith.