Patient Testimonial Release Consent

 

Purpose of Consent:

By signing this form, you are consenting to and acknowledging that your testimonial may be distributed by The Healing House in the interest of public education. If you would only like to share certain parts of your testimonial for public education, then please indicate which sections are approved to share in the last comment box that reads, ‘Is there anything else you would like to add?’

Right to Revoke:

You have the right to revoke this Release at any time by giving written notice of your revocation and submitting it to The Healing House.

Consent to Release: 

I hereby authorize The Healing House to use my testimonial and any information in the testimonial (unless specified otherwise) in its public relations and educational efforts. I understand and approve the disclosure by The Healing House of this testimonial information to the media and other individuals and entities that may be involved in The Healing House’s public relations efforts. I acknowledge that a follow-up for additional information regarding this testimonial could be necessary, and I am willing to participate in any related issues as they arise.

I understand that I am providing this information to The Healing House but that my care providers or any HH staff will not be disclosing any private information to the public (beyond first name, age, care summary and metrics), including identifying private health information in my medical records, and that my confidentiality is protected pursuant to federal and state statutes and regulations.  

I waive the right of further prior approval and hereby release The Healing House from all claims for damages of any kind based on the use of my testimonial. I am of legal age and freely sign this release, which I have read and understood.

 

2017 All Rights Reserved, TMS Therapy Clinic of Orlando, LLC dba The Healing House