Metagenics Inc. (“Metagenics”) is a health science company focused on helping individuals realize their health potential by partnering with health care professionals to provide patients with personalized tools and plans to improve their diet and lifestyle.

I hereby authorize my health care provider to disclose to Metagenics, and for Metagenics to use and disclose my health information for the following purposes:

• Marketing. To receive marketing communications, advertisements, or other communications from Metagenics about products, service, programs, scientific research, surveys, and other special initiatives.
• Permission to Text/Auto-Dial. I consent to receive recurring automated text messages and/or prerecorded calls from Metagenics and/or its agents or vendors at the phone number(s) that I provided on the previous screen for any purpose, including messages, that may include order confirmations, refill reminders, marketing, sales, or offers. Consent is not a condition to purchase any goods or services. Message and data rates may apply. Text STOP to cancel.

Information to be Disclosed: Metagenics may use and disclose the following health information about me: name, mailing address, email address, telephone number, and products purchased.

• I acknowledge that I have the right to revoke this authorization at any time, except to the extent that protected health information has already been used and disclosed by Metagenics in reliance on this authorization. I understand that I must revoke this authorization in writing by sending a dated and signed letter stating that I revoke this authorization to the Privacy Officer at the following address: Metagenics, Inc. 25 Enterprise #200, Aliso Viejo, CA 92656. I acknowledge that the revocation of the authorization will be effective upon receipt of the revocation letter by the Privacy Officer.
• I understand that this authorization is voluntary and that I do not have to sign this authorization. Metagenics will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

Expiration: Unless otherwise revoked, this authorization will expire on December 31, 2050.