We’d love to hear from you! Tell us how Inogen has helped you to achieve your independence. If you would like to submit a testimonial to be posted on Inogen’s website or used in other Inogen marketing materials to help spread awareness of Inogen to other oxygen users, please read and complete the enclosed release form and authorization form and send both forms back to us, along with a short testimonial and a picture of you with your Inogen One.

TESTIMONIAL RELEASE AND AFFIDAVIT

For valuable consideration, the receipt and sufficiency of which are hereby acknowledged, and intending to be legally bound, I hereby give Inogen, its representatives and assigns, employees, or any person, persons, corporation or corporations acting under its permission or authority, or any person, persons, corporation or corporations for whom it might be acting (collectively, “Inogen”), the right and permission to publish, reproduce, distribute and/or otherwise use and disclose to the general public any still or moving photographic or sound recording of me, in whole or in part (the “Performance”), including but not limited to any statement or endorsement (including any letter or photograph) or any portions thereof (the “Testimonial”), made by me regarding or related to the product known as Inogen One (the “Product”), in such manner, for such purposes and with such frequency as it shall determine in its sole discretion without further compensation or consideration to me and without further authorization by me.

I further acknowledge that identifying information accompanying the Performance or Testimonial may be released by Inogen to the general public, such as my name, my city of residence, and the fact that I receive health care services, and that this information (along with the Performance and Testimonial) may be released for the purpose of advertising, marketing, or generally promoting Inogen’s products and services, including the Product. I further acknowledge that between myself and Inogen, Inogen shall be the exclusive owner of all rights, title and interest in and to any original works authored by Inogen, or created under Inogen’s direction, that use, incorporate or adapt the Performance and/or Testimonial, subject to my preexisting rights in any of the Performance and Testimonial, which I have made Inogen aware of, released hereunder..

I also represent and warrant (1) that any statements or endorsement made by me in the Performance and/or Testimonial are factually accurate and represent my honest opinions, findings, beliefs, or experiences, (2) that I was not compensated in exchange for my endorsement (although I may have received a nominal reimbursement for my time and expenses), (3) I am not a member of any union or guild such as Screen Actors Guild or American Federation of Television and Radio Artists, which may have jurisdiction over this matter, and (4) the Performance and Testimonial are either original to me and/or owned by me and/or I have full authority from the owner of the Performance and Testimonial to grant this release and give Inogen permission to use the Performance and Testimonial as described herein.

I hereby waive all rights of inspection or approval with regard to any recording, taping, reproduction, proposed printed, online, or audio or video publication and/or other use of the Performance and/or Testimonial in any medium now known or hereafter developed. I also hereby release, discharge and agree to hold harmless Inogen and any person, persons, corporation or corporations distributing or disseminating advertising containing the Performance and/or Testimonial, from and against any and all liability resulting from its use of the Performance and/or Testimonial or related to my use of the Product.

I hereby warrant that I am over eighteen years of age, and competent to contract in my own name. I have read this release and affidavit before affixing my signature below, and warrant that I fully understand the contents thereof.

  
NameDate
 
Address
   
CityStateZip
 
Telephone
  
WitnessDate

Testimonial Statement:
 
 
 
 
 

Please include a picture of you and your Inogen One as well.

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

I authorize Inogen, Inc. and its employees and agents to use on Inogen’s website and in written marketing materials, for the purpose of marketing Inogen’s products, the following protected health information: My first name, the first initial of my last name, my city of residence, my photograph, and the video or written testimonial I have provided to Inogen at the time this authorization is completed.

I understand that this authorization is voluntary, and that Inogen will not condition treatment, payment, enrollment or eligibility for benefits on my providing authorization. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by federal regulations regarding privacy of health information. I also understand that I have the right to revoke this authorization at any time, except to the extent that Inogen has taken action in reliance on the authorization, by sending written notice of revocation to Inogen at the following address:

Compliance Officer
Inogen, Inc.
326 Bollay Dr
Goleta, CA 93117.

If I do not revoke this authorization, it will expire 15 years from the date above.

I understand that I will receive a copy of this authorization.

  
Patient SignatureDate
 
Printed Name