Patient Video Testimonial Release Form printable pdf download

Patient Video Testimonial Release Form

Date __________________

Authorization and Release of Testimonial Information

I understand my video testimonial (the "Testimonial") made on behalf of [Practice Name]

(hereinafter called "The Practice") may be used in connection with publicizing and promoting

The Practice. I authorize The Practice to use my name, brief biographical information, and the

Testimonial as defined on this form.

I hereby irrevocably authorize The Practice to copy, exhibit, publish or distribute the Testimonial

for purposes of publicizing The Practice’s services or for any other lawful purpose. These

statements may be used in printed publications, multimedia presentations, on websites or in any

other distribution media. I agree that I will make no monetary or other claim against The Practice

for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy,

wherein my testimonial appears.

I hereby hold harmless and release The Practice from all claims, demands and causes of action

which I, my heirs, representatives, executors, administrators or any other persons acting on my

behalf or on behalf of my estate have or may have by reason of this authorization.

Signature: ______________________________________________________________

I have read the authorization and release information and give my consent for the use of my

testimonial as indicated above.

Printed Name: _________________________________________

Signature:

_________________________________________

Email:

_________________________________________

Address:

_________________________________________

City, State, Zip: ________________________________________

Patient Video Testimonial Release Form