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Consent Forms

Thank you for allowing us to use your comments.

Please open and complete both consent forms below, including your signature. One form is your authorization for us to use the information you share with us, and the other is a PHI (Protected Health Information) compliance form which is required anytime we discuss your healthcare experience.

You have two options for completing the forms:

  1. Open and complete the form and follow the directions below to create a digital signature (if you plan to digitally sign the form, open it in Adobe Acrobat Reader); or
  2. Open and complete the form except for the signature. Print it, sign it, scan or take a photo of it and email the signed copy to us.

Steps to Create a Digital Signature:

  • Open the form using Adobe Acrobat Reader (or you will be able to convert to Adobe Acrobat Reader when you open the file)
  • Complete all shaded fields except the Signature field
  • Click on “Tools” on the toolbar
  • Click Fill & Sign
  • Click Fill & Sign again
  • Click the Sign Icon at the top of the screen
  • Click Add Signature
  • Type your name in the box
  • Click Apply
  • Drag your signature to the Signature field
  • Click a Save icon, or click File then Save on the toolbar
  • Name the file in “Save as”
  • Close
  • At this point, you can click the Share button in the upper right, and email the file directly to us (we will give you an email address to use) from the site, or you can open your email account and attach the saved file to an email and send to us.

Thanks again for your support!


Appearance Photo Media and Testimonials Consent Form

Authorization for Media Use or Disclosure of PHI