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Patient Testimonial Form

Patient Testimonial Form

Thank you for sharing your patient experience with us. Take a moment to fill out the form below.

Max. file size: 50 MB.
I authorize members of the Memorial Health System team or the media to contact me for more information
I authorize members of the Memorial Marketing staff to take and publish photographs, videos, or written/audio accounts that document my (or my child's) condition or treatment in newspapers, magazines, other publications, television, motion pictures, Internet, or other media, which will be circulated to the general public for news, marketing, business, or any other purpose, or to provide access to members of the public media to do the same(Required)
I consent to the use of my (or my child's) name with these photographs or videos.(Required)
I release any and all rights or claims for payment or royalties in connection with any exhibition, televising, or other showing of these motion pictures, videotapes, or photographs, regardless of whether such exhibition, televising, or other showing is under philanthropic, commercial, or private sponsorship, and regardless of whether a fee of admission or film rental is charged. I agree to release and hold harmless Memorial Health System, its trustees, agents, officers, and employees from any liability related to the making or use of motion pictures, videotapes, or photographs for the purposes stated above. I understand that I may refuse to sign this authorization, and that my refusal to sign will not affect my/my child's ability to obtain treatment. I understand that this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance of this authorization. I understand that the information released may be subject to re-disclosure by some recipients and may no longer be protected by federal or state privacy rules related to health information. Authorization for use in treatment or at patient or family's request will not expire. Authorization for other uses and disclosures indicated above will expire 10 years from the date of signature; however, I acknowledge Memorial is unable to control the continued use of photographs or videos by non-Memorial personnel after expiration of this authorization.(Required)
Patient Name(Required)
Patient Birthdate(Required)
Preferred method of contact

To revoke this authorization, please send a written request with a copy of this form to the address below:
Memorial Health System Marketing
P.O. Box 1810
Gulfport, MS 39501