**AUTHORISATION FORM**  
I understand that Figure 1, Inc. (the "Recipient") makes available an image-sharing application called the Figure 1 Application (the "App") that is used by healthcare professionals and others to share de-identified images of medical conditions or injuries. My physician or other healthcare professional has asked me, and I hereby agree, to allow him or her to:

1. take photos (or otherwise capture images, such as by a scan or X-ray) of part of my body (the "Images");  
2. remove any identifying details that would allow someone to identify me from the Images; and  
3. transfer the Images to the Recipient to be shared with other users of the App for educational and informational purposes to promote the sharing of medical knowledge.

I understand that I may revoke this Authorization at any time prior to the images being transferred to Figure 1. My revocation will only be effective if I submit it in writing to User. I understand that I am not required to sign this Authorization, and that my refusal to sign will not affect my eligibility for treatment, services or other benefits provided to me by User. I understand that, in accordance with the App’s terms of use, the Images are only to be transferred by the User to the Recipient after the Images have been fully de-identified and that the Recipient will have no means to connect my identity to the Images. Accordingly, the de-identified Images will no longer constitute personal data and will not be protected as such. I understand that the de-identified Images may be used for additional purposes by the Recipient in connection with products and services that may be developed in the future. I understand that I will receive no compensation for consenting to the capture or use of the Images.

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Signature of Patient or Patient’s Representative  
Print Name  
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Date  
Description of Representative’s Authority to Act for Patient