Submit a Testimonial

Please Review Our Legal Agreement

I hereby authorize my testimonial to be used for testimonial advertisement in Liska, Exnicios and Nungesser’s promotional material, including Liska, Exnicios and Nungesser’s website, brochures, and advertisements. I waive the right of prior approval and hereby release and discharge Liska, Exnicios and Nungesser and all persons acting under the permission and authority of Liska, Exnicios and Nungesser from liability, damages, compensation or actions of any kind based on the use of my testimonial or information in the testimonial.

By signing 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 sign this consent to release my patient testimonial.

Participant’s Signature: (Typing your name here indicates that all of the above information is accurate and acts as your electronic signature.)