Thank you for sharing your experience with us. This form gives us your permission to record, use, and share your video testimonial. Please read it carefully before signing. If you have any questions, please ask our staff before signing.
1. Patient / Participant Information
2. Consent to Record
I voluntarily agree to be video and/or audio recorded by [Practice Name] ("the Practice") or its authorized marketing representative (including DoctorsInternet.com) for the purpose of creating a patient testimonial. I understand that participation is completely voluntary, that I am not required to provide a testimonial in order to receive treatment, and that declining will not affect my care in any way.
3. Grant of Rights — Use of My Testimonial
I grant the Practice and its marketing representatives a non-exclusive, worldwide, royalty-free, perpetual license to record, edit, reproduce, publish, and distribute my name, likeness, voice, image, and statements ("the Content") in any of the following:
• The Practice's website and landing pages
• Social media platforms, including Meta (Facebook and Instagram), YouTube, TikTok, and Google
• Paid digital advertising, including Meta Ads, Google Ads, and display/video ads
• Print materials, brochures, and in-office displays
• Email marketing and newsletters
I understand the Practice may edit, crop, or caption the Content for length and clarity, but the Practice will not alter the Content in a way that changes its meaning or misrepresents my statements.
4. Voluntary Disclosure of Health Information (HIPAA Acknowledgment)
I understand that my testimonial may reference my dental treatment, appearance, or experience at the Practice, which may be considered protected health information (PHI) under HIPAA. By signing this form, I voluntarily choose to disclose this information publicly and authorize the Practice to use it as described above. I understand this authorization is separate from, and in addition to, the Practice's standard Notice of Privacy Practices, and that information I choose to share in this testimonial will no longer be protected once it is made public.
5. No Compensation
I understand that I will not receive any payment, discount, or other compensation in exchange for providing this testimonial, unless otherwise agreed to in writing separately.
6. Right to Revoke
I understand I may revoke this consent at any time by submitting a written request to the Practice. I understand that revocation will apply to future use of the Content going forward, but the Practice cannot guarantee removal of copies already downloaded, shared, or distributed by third parties (for example, previously served ads or shared social posts) prior to the date of revocation.
7. Release of Liability
I release the Practice, its owners, employees, and marketing representatives from any claims, liability, or demands arising from the use of my Content as described in this form, including claims for defamation, invasion of privacy, or right of publicity.
8. Parent / Guardian Consent (if patient is a minor)
If the patient is under 18 years of age, a parent or legal guardian must read, sign, and complete this section on the minor's behalf.
9. Acknowledgment & Signature
I confirm that I have read and understood this form, that I am 18 years of age or older (or am signing as the parent/legal guardian of a minor patient), and that I voluntarily consent to the terms above.
If you have your own video or photos you'd like to include with your consent — in addition to anything recorded by our team — you're welcome to upload it below.
This is a general-purpose template and is not a substitute for legal advice. Requirements for media releases and HIPAA-related authorizations can vary by state and by practice. Please have this form reviewed by the practice's healthcare attorney or compliance advisor before use.
