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 educational draft, version 1.0, September 20, 2026. Not reviewed or approved by an attorney or clinician. A qualified professional must adapt and approve it for the practice, jurisdiction, patient and actual service before use. A signature does not replace an informed discussion. Adult templates only; not a minor or proxy-consent workflow.
Inside the template
Five pages: practice preparation, patient discussion, two completion pages, and an implementation/source appendix. The PDF has fillable text fields; use the Word version to revise the language. 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
Approved statement
I authorize use and disclosure of the specific quotation, transcript or recording identified below and only the identifying details I select. The practice must not change the meaning of my experience. New statements or materially different edits require my approval.
Purpose and recipients
The purposes, recipients and publication channels are listed below. This permission does not authorize access to my full clinical record or publication of unrelated photographs.
My rights
Signing is voluntary. Refusing will not affect treatment, payment, health-plan enrollment or eligibility for benefits. I may revoke this authorization in writing using the practice contact below, except for action already taken in reliance on it. Recipients may share the disclosed information again, and it may no longer be protected by HIPAA. Public copies may be impossible to retrieve. I will receive a copy of this signed authorization.
Details to complete before signing
- Patient name
- Practice / person authorized to disclose
- Approved quote / attached transcript or recording ID
- Identifying details allowed
- Recipients / channels and purpose of each use
- Expiration date or event
- Written revocation contact and address
- Benefit to patient / material connection: none or describe
- Third-party remuneration to practice: none or describe
- Patient signature and date
- Copy supplied: 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.