Video-Permission

Your Information

So I know who to thank!

Full Name *

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Email Address *

So I can reach you if needed

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What are you giving permission for?

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Video recording Written testimonial or quote Photo or screenshot

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How should I identify you?

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Use my full name First name and last initial (e.g., Sarah T.) First name only Keep me anonymous

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Where can I share it?

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My website (drjennytalbert.com) Social media (Instagram, Facebook, etc.) Google Business reviews Print materials (brochures, office signage) All of the above — use it wherever!

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Permission & Acknowledgment

Please review and check both boxes *

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'm not receiving compensation, and that I can withdraw this permission at any time by emailing hello@drjennytalbert.com. 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.

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Electronic Signature

Type your full name as your signature *

This confirms your agreement to everything above

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Today's Date *

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You're the best. Seriously.

Your permission form has been submitted. Thank you for trusting me with your words — I'll treat them with care. If you ever want to update or withdraw your consent, just email hello@drjennytalbert.com.

Now come follow along on the journey:

@drjennytalbert

Testimonial Permission Form

You're the best. Seriously.