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Patient Testimonial Release Authorization Form

Full Name:


City, State:

Purpose of Authorization: I am providing Med Tourism Co, LLC with my client testimonial by signing this authorization form. They can publish it on their company websites, social media pages, emails, and other digital platforms. I agree that I am voluntarily sharing my testimonial, and I am receiving no financial remuneration for providing it.

Right to Revoke: I understand that I have the right to revoke this authorization at any time by providing a written request to the Customer Service at Med Tourism Co, LLC. I understand that if I choose to revoke this authorization, it will become effective on the day of the revocation of the authorization. Any prior uses and disclosures of my testimonial will not be subject to the revocation of the authorization. I understand that Med Tourism Co, LLC will make its best effort to remove my testimonial and protected health information from the Med Tourism Co, LLC’s website and other social media pages.

Components of my Testimonial: I understand that the client testimonial for Med Tourism Co, LLC will only include my name, location, photograph, video, and information provided to the organization in my testimonial.

By signing below, I agree and acknowledge that I have read and understood all of the elements of this authorization for use of my client testimonial. It does not require Med Tourism Co, LLC to remove my testimonial from the website or other social media pages unless I specifically request revocation of this authorization.

I prefer to be identified in the following way for my client testimonial:

My full first and last name (Sally Sample, City, State)
My first name and last initial only (Sally S., City, State)

Testimonial: (Impact on your life, your experience, and helpful tips for others)

Upload File:(max file size: 25MB)

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Digital Signature:(Type your full name):


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