PHYSICIAN NAME *

First Name

Last Name

Phone Number *

Country

(###)

###

####

Primary Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization *

Expert Reviewer. I hereby give my permission to C-SATS, its legal representatives and those acting under C-SATS authority, to list the information provided above in my reviewer profile.

Consent *

I agree to the terms of the C-SATS, Inc. Global Privacy Policy (add hyperlink to "global privacy policy" - https://www.csats.com/privacy-policy) and consent to the collection, use and disclosure of my personal information, including my biometric data, in accordance with this Privacy Policy. I understand that C-SATS shall have the right to use and publish my information, including my personal information, in the reviewer profile. I understand that I have the right to request my personal information be removed from my profile upon written notice to C-SATS (add hyperlink to "written notice to C-SATS" that opens an email to marketing-digitalsolutions@its.jnj.com), and that C-SATS shall have the right, at any time, to remove or update my information, including my personal information.

Accuracy of Information *

I have read this authorization and fully understand the contents thereof, and I represent that I have not entered into an agreement with any person or entity that would prevent me from giving this authorization. I agree that the information I have provided on this form is true and accurate. Should any of that information, including information relating to my credentials and authority to practice medicine change, I will promptly notify C-SATS (add hyperlink to "notify C-SATS" that opens an email to marketing-digitalsolutions@its.jnj.com).

Release of Liability *

C-SATS platform is not a medical device. It is not intended to replace formal medical education or training. It is designed for use by licensed surgeons who recognize/accept the English language. I forever release C-SATS and its affiliates, and their respective employees, agents, independent contractors, and assigns, from all claims and liabilities of my own and/or of third parties relating in any way to any information I provide or to my involvement with the reviewer profile. I agree that my information is not listed to reward or induce past or future orders, purchases, lease, use, or recommendations of Company products. I agree that my information will also be used by C-SATS to contact me regarding the reviewer profile, such as updates or changes.

Date

MM

DD

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