By submitting this form, you are agreeing to allow us to publish your survey on our website and social media channels.
I understand my photo or video testimonial (the "Testimonial") made on behalf of Anthony P. Urbanek, DDS, MS, MD (hereinafter called "The Practice") may be used in connection with publicizing and promoting The Practice. I authorize The Practice to use my name, brief biographical information, and the Testimonial as defined on this form.
I hereby irrevocably authorize The Practice to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Practice’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites, social media channels or in any other distribution media. I agree that I will make no monetary or other claim against The Practice for the use of the statement.
In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears.
I hereby hold harmless and release The Practice from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
You agree to and hereby indemnify, defend, and hold harmless PBHS, its Third Party Providers and their respective affiliates, employees, agents, contractors, assigns, licensees, and successors in interest (“Indemnified Parties”) from any and all claims, losses, liabilities, damages, fees, expenses, and costs (including attorneys’ fees, court costs, damage awards, and settlement amounts) that result from or relate to any claim or allegation against any Indemnified Party arising from you accessing or using the services provided under this Agreement (including any Third Party Services) or from any email or other communication generated or sent through such services or any content contained therein, whether or not in breach of this Agreement.
PBHS offers subscription text message programs. Customers may ask their agent to enroll them in a text message alert program. Once enrolled in SMS texting services, you will have an opportunity to confirm or decline the service via a reply to an initial text message you receive. By agreeing to these terms of service, you are confirming a subscription to this text message program. Message frequency varies.
PBHS does not have a separate charge for this service; however, message and data rates may apply from your mobile carrier. Subject to the terms and conditions of your mobile carrier, you may receive text messages sent to your mobile phone. Participation in the programs on this short code is standard rated.
By providing your consent to participate in this program, you approve any such charges from your mobile carrier. Charges for text messages may appear on your mobile phone bill or be deducted from your prepaid balance. PBHS reserves the right to terminate this SMS service, in whole or in part, at any time without notice. The information in any message may be subject to certain time lags and/or delays. You are responsible for managing the types of SMS texts you receive.
By e-mail: email@example.com
By Phone: 1-888-840-0739
We reserve the right to make changes to this policy. Any changes to this policy will be posted.