I hereby authorize Astrid Pujari, MD (aka Dr. Pujari), and those acting pursuant to her authority a nonexclusive grant to:​​
I understand the following:
I hereby release Astrid Pujari, MD and those acting pursuant to her authority from liability, claims, and demands for any violation of any personal or proprietary right I may have in connection with such use, including any and all claims for libel, defamation, or invasion of privacy. I have read and fully understand the terms of this release.
(please be patient, this may take a minute)