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Send us your testimonial
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Is this a revocation?
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Your name
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DOB
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I authorize Family Care Center or it's affiliate companies (Direct Care, Ketamine Colorado Springs, Solon Behavioral Health) to:
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Film my TMS treatment or ketamine IV therapy
Photograph my TMS treatment or ketamine IV therapy
Film my TMS or ketamine IV therapy testimonial
Document and share my TMS or ketamine IV therapy testimonial
Photograph me and share my TMS or ketamine IV therapy testimonial
I prefer that only the below description is used.
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Complete name
First name only
Initials only
By checking below, I authorize the above selected option for use on social media and give my consent freely as a public service without expecting payment.
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Yes
Testimonial:
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I understand that I may revoke my consent in writing at any time and that the used of my photo, video, and / or statement authorized by this release will immediately cease.
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I hereby revoke this Authorization to Disclose information.
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