Know the boundaries
Not for: A request for a positive review, a guarantee of typical results, or permission to disclose the full patient record.
Source-checked template, version 2.0, September 21, 2026. Practice review and adaptation are required before use. No independent clinician or attorney approval is claimed. Adult patient self-consent only; use a separately reviewed process for minors or representatives.
Inside the template
Two clean, unbranded patient-facing pages: the relevant discussion, specific choices and completion fields, and the patient decision with signatures. The PDF includes fillable fields and selection controls where applicable. Use the Word version to adapt the language. Sources and practice guidance stay on this page. Typed fields are not a verified electronic-signature service.
Actual sample page · Open to enlarge · Full editable files available below
Prepare your practice version
- Attach the final quote, transcript or recording ID for approval.
- Record the channels, audience, identifying details and expiry.
- Disclose material connections where required; permission does not substantiate a treatment claim.
- Do not make a reward depend on positive sentiment or hide material edits.
Public text preview
Language for the conversation
Voluntary choice
I can refuse this authorization without affecting my treatment, payment, health-plan enrollment or eligibility for benefits.
Written revocation
I may revoke this authorization by writing to the contact below. Revocation will not undo action already taken in reliance on my authorization. The practice must assess and stop future uses that are no longer authorized.
Public disclosure
Recipients may share my information again, and HIPAA may no longer protect it. Online material can be copied or archived beyond the practice's control; complete removal cannot be promised. I may be recognizable even without my name.
Details to complete before signing
- Practice name
- Visit / discussion date
- Patient full name
- Date of birth
- Exact approved quotation or attached transcript / recording ID and date
- Practice or person authorized to use / disclose
- Health or treatment details allowed
- Specific channels and recipients / recipient classes
- Purpose of each selected use and any limits
- Patient compensation (none / detail)
- Third-party payment to practice (none / detail)
- Written revocation contact and postal or email address
- Expiration date or event related to this use
- Patient initials
- Patient signature
- Date / time
- Clinician / practice representative name
- Signature / date
- Interpreter name / ID if used
- Language
- Copy provided to patient by
- Date / method
Common questions
Does signing make a testimonial claim acceptable?
No. The practice still needs to evaluate truthfulness, support for claims, typicality and material-connection disclosures under applicable advertising rules.
Can we use a review in an advertisement?
Do not assume a public review supplies all required permissions. Obtain appropriate approval for the exact promotional use and evaluate privacy and advertising obligations.