I hereby authorize Fair Wound Care, LLC, and its service providers to complete and send the attached letter on my behalf to the addressee and related parties.  I understand that this information may be used and retained by the addressee in accordance with applicable law.

I hereby consent to the use(s) of the information I provide described above and hereby release Fair Wound Care, LLC, and related parties, from any and all liability for of whatever kind or nature arising out of such use(s).