Description of article, content or photograph (the “Material”): ___________________________
Name of author submitting the Material: ________________________________________________
Contribution number (if known): ________________________________________________________
To be completed by the patient:
I give my consent for all or any part of the Material referenced above to appear in publications of the Andover House Inc. (ANHI) in any media worldwide, including Precision Nanomedicine and any derivative works or products. I understand that the Material may depict my medical conditions.
· I understand that: My name will not be published with the Material by Andover House, and ANHI will endeavor to maintain my anonymity. I understand, however, that it is possible that someone may recognize me from the images and/or accompanying content.
· The use of the Material relating to me may include, without limitation, publication in the printed and electronic editions of publications, on websites, in sublicensed or reprinted editions (including foreign language editions), and in other derivative works or products.
· I grant and release to the Publisher all rights, title, and interest that I may have in the Material. I understand that I will not receive, and am giving up any claim to receive, any payment or royalties in connection with the use of the Material
· The Material may be edited, modified, and retouched.
Signed: ______________________________________________ Date___________________________________
Print full name: ______________________________________________________________________________
If you are not the patient, what is your relationship to him/her____________________________________
Witness: _____________________________________________Date: __________________________________