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CONSENT TO INTERVIEW AND AUDIO and/or AUDIOVISUAL RECORDING

In consideration of receiving the NasoNeb® Sinus Therapy System and/or two bottles of the moisturizing nasal solution free of charge, the sufficiency of which is acknowledged by me, I hereby agree to participate in a product evaluation survey consisting of one or more interviews and surveys to be conducted by NasoNeb, Inc. (“NasoNeb”) and grant to NasoNeb and its agents, including NasoNeb’s assigns and successors, consent to the audio and/or audiovisual recording of my interview(s) and/or the use of the audio and/or audiovisual recording and information obtained through the recording, interview(s) and/or surveys in connection with NasoNeb’s product evaluation survey for the purpose of assisting NasoNeb to enhance its product and service offerings to its customers (the “Purpose”).

I hereby consent and grant to NasoNeb the right to use any information gathered via the audio and/or audiovisual recording, interview(s) and/or surveys for the Purpose and to the reproduction in full or in part of all such information in any materials whether in hard copy, electronic or any other form, and to produce other materials based on or derived from such materials comprising such information (collectively the “NASONEB MATERIALS”). I acknowledge that NasoNeb is the exclusive owner of all copyrights and other rights of ownership in and to the NASONEB MATERIALS and I hereby waive any rights to such NASONEB MATERIALS.

I acknowledge that the information I provide will be treated as confidential and will not be shared with other third parties without my consent.

This consent is binding on my heirs, administrators, and assigns or, if I am granting consent for a person other than me, that person’s heirs, administrators and assigns.

This consent and grant of right to use as it relates to the use of my personal information will remain in force until such time as I inform NasoNeb in writing of its revocation. Such revocation should be sent to the following email address privacy@nasoneb.com. The consent and grant of right to use the NASONEB MATERIALS, excluding my personal information, will remain in effect indefinitely.