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Patient Testimonial Release Consent

Purpose of Consent: By checking the box, you are consenting to Active Life & Sports Physical Therapy use and disclosure of the information in your testimonial and acknowledgement that the testimonial may be distributed to the public.

 

Right to Revoke: You have the right to revoke this Release at any time by giving us written notice of your revocation and submitting it to the Contact Person listed below. Please understand that revocation of this Release will not affect any action Active Life & Sports Physical Therapy took in reliance on this Release before receiving your revocation.

 

CONSENT TO RELEASE

 

I hereby authorize Active Life & Sports Physical Therapy to use my testimonial and any information in the testimonial in its public relations efforts. I understand and approve the disclosure by Active Life & Sports Physical Therapy of testimonial information to the media and other individuals and entities that may be involved in Active Life & Sports Physical Therapy ’s public relations efforts. I acknowledge that the media may be interested in my story, and I am willing to participate in media interviews as they arise.

 

I understand that I am providing the testimonial information to Active Life & Sports Physical Therapy and that my treating physical therapist will not be providing any information to Active Life & Sports Physical Therapy , including private health information in my medical records, the confidentiality of which may be protected by federal and state statutes and regulations, including, Health Insurance Portability and Accountability Act (HIPAA).

 

I waive the right of prior approval and hereby release Active Life & Sports Physical Therapy from all claims for damages of any kind based on the use of my testimonial or information in the testimonial. 

 

I am of legal age and agree to this release, which I have read and understood.

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