How did Life Line Screening help you? Did our services identify an unrecognized health problem, help you gain a greater understanding of your risk factors, or improve your health in some other way? We would love to hear your story. Please share your experience by filling out the form below.

* Required Fields *Your first name:   *Last name:   *Street address 1:   Street address 2:   *City:   *State:   Select One AL AK AR AZ CA CO CT DC DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   *Zip code:   *Phone number:   *Your e-mail address:   My Story:  Share how Life Line Screening helped you.   I have read, understand and agree to the terms of the testimonial agreement and release.   NAME, LIKENESS AND TESTIMONIAL AGREEMENT AND RELEASE This Name, Likeness and Testimonial Agreement and Release (“Agreement”) is made in Cleveland, Ohio by and between LIFE LINE SCREENING OF AMERICA LTD., an Ohio limited liability company and __________________________________________ (“Screening Participant”). The Agreement is executed electronically by the Screening Participant, in accordance with the Electronic Signatures Act (15 U.S.C. § 7001 et seq.). The Agreement is made at the date and time that the Screening Participant electronically checks the box on the on-line form, indicating that the Screening Participant acknowledges the Agreement and submits it to Life Line Screening of America, Ltd. In consideration of a complimentary health screening gift certificate received by Screening Participant, the mutual promises contained herein, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties hereto agree as follows: Screening Participant hereby grants permission to Life Line Screening of America, Ltd., and its successors, assigns and affiliated companies (collectively “the Company”), the irrevocable and permanent right to use the name, likeness and/or testimonial of Screening Participant, and irrevocably assigns to the Company all rights to use and reproduce such name, likeness and testimonial and to secure a copyright thereon anywhere throughout the world in the name of the Company, in accordance with the following terms and conditions: 1. The authority granted to the Company includes the ownership of and the right to use the name, likeness and/or testimonial of Screening Participant, separately or in any combination thereof, or in combination with stock photography showing persons other than Screening Participant, on marketing and/or advertising or other brochures or materials in any media form, including but not limited to printed material, television, radio, internet, or other medium, whether now existing or hereafter devised. All such materials shall be the sole property of the Company. The Screening Participant acknowledges transfer of all ownership rights to the Company. 2. If the Company uses such name and/or testimonial in connection with stock photography of other persons, the Screening Participant is not being depicted or portrayed in a factual manner. 3. The Company is under no obligation to use such a name, likeness and/or testimonial. 4. Screening participant warrants and represents that he or she has the authority to enter into this Agreement and that the Company’s exercise of its rights under this Agreement does not violate or infringe on any rights of any third party. 5. Screening Participant releases the Company from any claims arising out of this Agreement or the Company’s exercise of its rights under this Agreement, including but not limited to claims for invasion of privacy, infringement of any right of publicity or public light, defamation, or any other claim. 6. Screening Participant is not entitled to any further compensation. 7. This Agreement is governed by Ohio law. Any dispute involving this Agreement must be brought only and exclusively in the state or federal courts located in Cuyahoga County, Ohio.