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Tell us your story

If you have a story to share about your new life using alli^®, we want to know. Simply fill out the form below and then submit your story.

For help on what to include in your story and how to send it, review our real story tips.

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First name*

Last name*

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Age*

Email*

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Address*

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How long have you been using alli? *

What was your starting weight?*

How many pounds have you lost?*

What is your goal weight?*

How satisfied are you with the program?*

Have you enrolled in myalliplan™?*

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If yes, for how long have you been enrolled in myalliplan?

alli Testimonials Authorization and Release Agreement

alli Testimonials Authorization and Release Agreement

In exchange for the opportunity to participate  in the alli testimonials (the “Testimonial”) and for other good and valuable consideration, I hereby grant to GlaxoSmithKline Consumer Healthcare (“GSKCH”) and imc2, LLC, and each of their parent companies, affiliated companies, subsidiaries, successors, licensees, assigns, officers, agents, employees, and those acting with their authority, including but not limited to any of GSKCH’s advertising agencies (collectively, the “Released Parties”), the unqualified right to reproduce, copyright, publish, circulate, or otherwise use my name, image, photograph, likeness, voice and signature, and any still photographs, videotapes, and/or audio tapes of me produced by GSKCH or on their behalf by any other entity or person. Hereinafter, “my information.” I warrant that I am the owner of said “information” and I give express permission to the released parties to make alterations as required to meet the requirements for broadcast or dissemination. This authorization and release covers the use of same, in whole or in part, in any published form and any present or future media, including, but not limited to, print, broadcast TV and radio programming, internet publication, electronic media, digital versatile discs (“DVDs”) or other form of distribution in any part of the world.  

I fully understand that this Authorization and Release Agreement constitutes a complete release of all claims against GSKCH, and the Released Parties, by reason of any such use of my name, image, photograph, likeness, voice and signature, and any still photographs, videotapes, and/or audio tapes, produced by any Released Party or any other entity or person on GSKCH’s behalf. I will not institute or support any claims or actions against any Released Party, arising out of the exercise of the rights granted hereunder.  Accordingly, I hereby release and forever discharge the Released Parties from any claim, action and demand whatsoever, in law or in equity, that I may have now or may have in the future including, but not limited to, claims for defamation, violation of rights of privacy and/or publicity, intentional infliction of emotional distress, and/or copyright infringement.

I warrant and represent that all statements, remarks, and all other information I make, give, or relate to any Released Party or any other entity or person in conjunction with my participation in the Testimonials are factually accurate and represent my true opinion and experience.

I agree that no promises have been made to me other than as set forth in this Authorization and Release Agreement, and I have not relied upon any representations or other statements not contained in this document. I understand that GSKCH is making substantial expenditures in reliance upon the foregoing. I understand that my information may not be used. 

I represent and warrant that I am eighteen years of age or older and am under no restrictions from entering into this Agreement.  I further represent that I have read and understood this agreement. This agreement shall be binding upon myself and my heirs, executors, administrators, legal representatives and assigns.  This Agreement shall exist and be construed according to the laws of the State of New York.


	I have read the release and agree to the terms set forth by GSK.

By submitting this form you are giving GlaxoSmithKline Consumer Healthcare permission to provide you with health information, promotional offers, relevant product news and surveys that request your feedback. In the future if you do not wish to receive this information, you will be given the opportunity to opt-out. Please click here to read our Privacy Statement.

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