Vetericyn Plus Experience Submission Give Your Testimonial

VETERINARIAN/CLINICAL INFORMATION

Submitors Position *

Clinic Name *

First Name *

Last Name *

City/Province

State

Zip Code

Country

Phone

Fax

Email *

CASE REPORT

Species *

Breed *

Age *

Sex *

Type of problem treated? *

Locations on patient? *

Time of accident until Veterinary care was administered: *

Duration of treatment? *

Vetericyn product(s} used? *

Frequency of application? *

Other products or drugs administered? *

Comments & Key Notes on Case Report *

Please be brief but complete.

File Upload

A single image may be uploaded in .png, .jpg, .gif format. OR Please email your photos to your Vetericyn Representative or email them to Dr. Melinda Mayfield, Vetericyn's Technical Services Veterinarian, at melindam@innovacyn.com. Please include time/date where possible.

Click to Read our Authorization, Release and Agreement

I hereby give and grant to Innovacyn, Inc. (hereinafter “Innovacyn”) and those acting with and under Innovacyn’s permission or upon authority of Innovacyn, the unrestricted right and permission to use a recording of my voice and other sounds of mine, or to substitute another’s voice for mine, and to use quotes provided by me, and to photograph me or use photographs provided by me made through electronic video tape, motion picture, still photography or otherwise, either with or without sound, in whole or in part, and use, reuse, publish, re-publish, display any such voice, sounds, quotes and/or photographs in which I may be included (hereinafter referred to as “MEDIA”) in whole or in part, composite or distorted, in character or form, all without restriction as to changes or alterations in the MEDIA whether previous, concurrent or subsequent to the date of this Agreement, and/or reproductions thereof, in color, sound or otherwise, for any use through any media and/or any other exhibition for any purpose whatsoever, including, but not limited to, advertising and publicity purposes.

I understand and agree that any publicity that I might receive as a result of the use of my voice or other sounds of mine, quotes, photographs, or my name or likeness shall be adequate consideration for this Authorization, Release and Agreement.

I understand and agree that Innovacyn has no obligation to use my voice, sounds, quotes, and/or photographs in any advertising. I hereby waive any right that I may have to inspect or approve the MEDIA or the materials into which they may be incorporated or any use whatsoever with which they may be associated.

I hereby release and discharge Innovacyn and its agents, affiliates, employees, successors and assigns from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite or whole form, whether intentional or otherwise, that may exist in the MEDIA or in any publications thereof, and from any liability from claims that may arise regarding use of the MEDIA, my image or other material that depicts, quotes or otherwise represents me, including but not limited to claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, or copyright and all other claims.

I understand and agree that this Authorization, Release and Agreement shall be effective forever from the date hereof and shall be applicable throughout the universe.
I hereby warrant that I am of full age* and have every right to contract in my own name in execution of this Authorization, Release and Agreement. I state further that I have read this Authorization, Release and Agreement in its entirety prior to my execution hereof, and that I am fully familiar with and in agreement with the contents hereof.

Further, I acknowledge that Innovacyn, Inc may modify my testimonial due to regulatory requirements and compliance issues.

* I hereby certify that I am twenty-one years of age or over. (If not twenty-one years of age or over, this Release must be submitted only by a parent or guardian).

Consent To Release?

Yes