PATIENT TESTIMONIAL

We will only publish your testimonial upon your permission and after removing any sensitive identifying information per your direction.

I. Demographic Information


II. Testimonial


III. Additional Terms and Conditions

I understand that I may revoke my testimonial authorization at any time by informing the Director of Marketing, Lori Boyd in writing that I am revoking my authorization. I understand that my revocation does not apply to the extent that St. Mary’s Regional Medical Center, UHS of Delaware, Inc., or any of their affiliates have already published or used my testimonial in reliance on this authorization. I further understand that my future treatment will not be affected by whether or not I sign this authorization.

If I authorized publication, then I acknowledge that the testimonial will be modified to the extent necessary to remove any sensitive identifying information or for editorial considerations. I have had the opportunity to read and consider the contents of this authorization. My submission indicates that I confirm that the contents hereof are consistent with my direction.