Medgate

4/F Dolmar Gold Tower,

107 C. Palanca Street,
Legaspi Village, Makati City
T +632 8705 0700
medgate.ph

I, the undersigned, hereby authorize MEDGATE PHILIPPINES INC. to photograph me, take
video footage of me, and/or make electronic sound recordings of me, herein referred to as
photographic or electronic reproductions.
I authorize the use of any such photographic or electronic reproductions of me for any purpose,
including, but not limited to educational and other public media as may be deemed appropriate
by Medgate. I understand that I may be identifiable from such photographic or electronic
reproduction. The company can retain my information for a period of five years from the date
of Resignation/Termination of my contract. I agree that my information will be
deleted/destroyed after this period.
I understand that there will be no financial or other remuneration for recording me, either for
initial or subsequent transmission or playback. I waive any rights, claims, or interest I may have
to control the use of my identity or likeness in whatever media used.

THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY

UNDERSTANDS IT.

Agreed and accepted by:

Name: ______________________________________________________________
KARL STEPHEN A. AGATON, MD

Address:_____________________________________________________________
UNIT 12A AURORA GARDENS TOWER 2, AURORA BLVD., SAN JUAN

____________________________________________________________________
Signature:____________________________________________________________
Date: ______________________________________________________________
MAY 19, 2022

Witness for the undersigned:

Name: ______________________________________________________________
Signature: ___________________________________________________________
Date: _______________________________________________________________