Authorization for use of Health Information

Last Revised December 14, 2016

Theryon Inc. (“we” or “us”) respects the privacy of your personal and medical information that is disclosed to us in the course of our relationship with you. We will collect your health information, directly or indirectly, from you through your interaction with our website, application, and services (collectively the “Site”). We may also collect health information about you, directly or indirectly, from other users of the Site with whom you make appointments. You hereby authorize physical therapists that provide health services to in connection with the Site to disclose your health information to us for purposes of providing the Site, and you authorize us to retain a copy of such health information after our relationship with such physical therapist has ended for purposes of continuing to provide the Site and administrative services to such physical therapists. You also hereby authorize us, and any third party vendors acting on our behalf, to use all, or any part of, your health information to perform our applicable services, including without limitation the Site.

We may use and disclose to third party vendors your name, mailing address, email address or other personal information for the purpose of sending you materials that market or promote health care products, services or therapies, or services offered by us or the Site. You understand that we may receive direct or indirect payment from the third-party companies whose products or services are being promoted in such communications.

As used in this Site, the term “health information” means all information relating to your past, present, or future physical or mental health or condition; the provision of health care to you; or the past, present, or future payment for the provision of health care to you. It includes such information regardless of whether it was created before or after your execution of this Site. It also includes such information regardless of whether it was: (i) collected by us in connection with the Site; or (ii) shared or submitted in connection with the Site by you, or by other users of the Site.

You understand that you have the right to revoke this authorization in writing at any time by sending written notification to Theryon, Inc. at You understand that a revocation is not effective to the extent Theryon, Inc. has already relied on the authorization to use or disclose your health information as described above. This authorization will remain in effect unless revoked in writing in the above specified manner.

Your healthcare and payment for your healthcare will not be affected if you do not sign this Authorization; however, it may affect your continued use of the Site.

If you are signing this authorization on behalf of someone else, you represent and warrant that you have all legal rights necessary to provide this authorization on behalf of the person for whom you are agreeing.

___ I authorize
___ I do not authorize