Cranial Technologies

This Appearance Release allows Cranial Technologies to use your child’s image or video and/or audio recording in connection with education, training and promotion of certain Cranial Technologies’ products and provision of services. For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby grant to Cranial Technologies, Inc. and its affiliates, subsidiaries, licensees, agents, successors, designees, and assigns and any entity partnered with Cranial Technologies, Inc. (collectively, “Cranial Technologies”) the right to use my name, likeness, voice, conversation, sounds, and other similar items (collectively, my “Appearance(s)”) as follows: I agree that Cranial Technologies shall have the right to create and capture audiovisual, audio-only, visual-only works, including the production of video and/or audio tapes, photographs, films, and/or recordings of and from my Appearance (the “Content”) by any method of recording in connection with education, training and promotion of certain Cranial Technologies’ products and provision of services to me (the “Purpose”). I agree that no consideration shall be due to me for the use of my Appearance, and Cranial Technologies shall not be obligated to pay me or any third party any consideration whatsoever, regardless of the time or method of any use of the Content. I agree that Cranial Technologies shall forever own all rights, including copyright, in the Content and the results and proceeds of such Content, and shall have the irrevocable right to use, and license others to use, the Content in whole or in part, an unlimited number of times, in all languages, in all media whether now known or hereafter devised, anywhere in the universe to the extent necessary for use in connection with the Purpose. Cranial Technologies shall have the right to edit the Content in any manner or form. I hereby release, discharge, and hold harmless Cranial Technologies from all claims, demands, or causes of action that I may have, including without limitation, claims based upon defamation, invasion of privacy, rights of publicity, commercial disparagement, or any other claims arising from the creation of or use of the Content or my Appearance. Cranial Technologies is not obligated to actually use my Appearance or the Content in connection with the Purpose. This Appearance Release shall be governed by the laws of the State of [Arizona] (excluding its conflicts of law principles), regardless of the place of its physical execution and shall be binding on me and my successors, parents, licensees, legal representatives, heirs, and assigns (as applicable). I hereby submit to the jurisdiction of the state and federal courts of [Phoenix, Arizona,] to resolve any dispute arising out of or resulting from this Appearance Release. I shall not raise, and hereby waive, any defenses based upon improper venue, inconvenience of the forum, lack of personal jurisdiction, or the sufficiency of service of process. Termination of this Appearance Release, for any reason, shall not affect Cranial Technologies’ rights in the Content. Cranial Technologies may assign its rights in the Content, in whole or in part, to any individual or entity, without restriction. This Appearance Release represents the entire understanding and supersedes all prior understandings between the parties relating to the subject matter herein. I hereby expressly approve of and consent to the terms of this Appearance Release and the agreements and promises made by the minor in this Appearance Release. F541 Rev00 ECO24-203 Effective Date: 09/23/2024

Name of Company: Cranial Technologies, Inc. Address: 1405 W. Auto Drive, Fl. 2, Tempe AZ 85284 Email: [email protected] Telephone: 866-362-2263 I hereby authorize the use and disclosure of individually identifiable health information relating to the patient listed above as described below: Specific description of the information to be used or disclosed: Clinical data, DSi® imaging and photography created and/or collected at the clinic or during the treatment process. The above information will be called “Authorized Information” throughout the rest of this form. Persons or class of persons authorized to make the use or disclosure of authorized information: Cranial Technologies, Inc. ▪ I understand that such Authorized Information may be published by various journals in any print, visual or electronic media, specifically including, but not limited to, medical journals and textbooks, for the purpose of informing the medical profession or the general public about plagiocephaly. Neither I nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the photographs may portray features, which shall make the patient’s identity recognizable. ▪ I understand that such Authorized Information may be used on the web site or social media channels of Cranial Technologies, Inc. ▪ I understand that such Authorized Information may be used by Cranial Technologies, Inc. for internal training and educational purposes. ▪ I understand that this authorization will expire upon the minor's age of majority unless revoked earlier by patient's representative. I understand that expiration will not affect any actions taken by Cranial Technologies, Inc. before the expiration. ▪ I understand that I may revoke this authorization at any time by notifying Cranial Technologies, Inc. in writing. However, if I choose to do so, I understand that my revocation will not affect any actions taken by Cranial Technologies, Inc. before receiving my revocation. ▪ I understand that I may refuse to sign this authorization and that my refusal to sign in no way affects my treatment, payment, or eligibility for benefits. ▪ I understand that Cranial Technologies, Inc. may require me to sign an authorization prior to receiving research-related treatment or treatment solely for the purpose of creating health information for another party and that Cranial Technologies, Inc. will not provide such research-related treatment unless I provide this authorization. ▪ I understand that the person or entity I am authorizing to use and/or disclose Authorized Information for marketing purposes may receive either direct or indirect compensation for doing so. ▪ I understand that the information disclosed, or some portion thereof, may be protected by state law and/or HIPAA. I further understand that, because the entity receiving the information is not a health care provider or health plan covered by HIPAA, such entity may re-disclose the information.

F541 Rev00 ECO24-203 Effective Date: 09/23/2024