Become a Plasma Partner

For valuable consideration received, I hereby grant Olympus America Inc., and/or its affiliates, representatives, and those acting with its authority or permission (collectively, “Olympus”) the right and permission to use, publish, depict, and display, my name, image (if supplied), the name of my employer, and field of expertise, on Olympus’ physician finder website. I hereby warrant that I am of full age and have the right to contract in my own name, and if I am employed by an institution, that I have the authority to execute this Consent and Authorization on behalf of my institution.