The undersigned hereby consents, upon the advice of counsel, that all matters and issues relating to my physical or mental condition or medical history, including, without limitation, whether my physical or mental condition arises from any preexisting disability, may be discussed and considered by (company) in open public meeting, and I hereby waive any right to have my physical or mental condition or medical history discussed and evaluated by (company).
By (your name)
Date: (date)