Thank you for sharing your experience with me!

This quick form gives me permission to use your testimonial so I can help other people find care they feel good about. Everything below is straightforward, and you can change your mind at any time.


Testimonial Permission Form

Fields marked as required must be completed before submitting.

So I can reach you if needed
What type of testimonial are you giving permission for? *
Select all that apply
How would you like to be identified? *
Choose your comfort level
Where can I use your testimonial? *
Select all you’re comfortable with
Consent Agreement *

I voluntarily give Dr. Jenny Talbert permission to use my testimonial as described above. I understand my testimonial may be edited for length or clarity (but not meaning), that I am not receiving compensation, and that I can withdraw this permission at any time by emailing hello@drjennytalbert.com.

HIPAA Acknowledgment *

I understand that by providing a testimonial, I am voluntarily choosing to share information about my experience as a patient. This is my choice and is not required. Dr. Talbert has not asked me to disclose any specific health information, and I understand that once shared publicly, this information may no longer be protected under HIPAA.

This confirms your agreement to everything above
If your device doesn’t show a date picker, you can type the date in MM/DD/YYYY format.

Submit My Permission By submitting, you confirm the information above is accurate.