Release and Acknowledgment

By participating in this survey, I hereby consent and agree to provide my honest feedback to Peak Performance for Men (“the Company”) for the purposes of improving its offerings, customer service, and patient value.  I understand that this survey is being conducted by a third-party (NAVSTAR Advisors), that my data will be anonymized and aggregated, and that it will be used only for internal Company purposes.  I understand and acknowledge that I have certain legal rights as it pertains to health information and privacy, and I waive all such protections for the purpose of completing this survey.  I further understand that, I also waive these legal rights if I call anyone at NAVSTAR Advisors and share my health information or other perspectives with them, or if I agree to accept a call from anyone at NAVSTAR Advisors. 

    The information which will be asked of me will include how many treatments I received, how effective I believe them to be, if I would be willing to undertake additional treatments, my general opinion of the treatments, and other similar information.

    Effective Date:  This release and acknowledgment shall be effective on the date the survey is initiated and shall be effective for as long as the anonymized data is accessible to Peak Performance for Men or NAVSTAR Advisors.  I acknowledge that I may voluntarily refuse to execute this Release and Acknowledgement simply by choosing not to participate in the survey which I have been presented.

    I understand that this Release and Acknowledgment impacts the rights and protections which I have under federal law, specifically the law commonly referred to as HIPAA, as well state privacy and healthcare laws.  I understand I am free to consult with an attorney of my choosing prior to executing this Release and Acknowledgment.  I agree to waive any right I may have to initiate any civil action or claim for money against Peak Performance for Men or NAVSTAR Advisors for any use of any information which I provide in response to questions in the survey attached, and understand that Peak Performance for Men is not directly conducting the study, but a third-party, NAVSTAR Advisors, has been contracted for that purpose.

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