Chiropractic Success Story Form

I authorize the Sherman College Chiropractic Center (SCCC) and my SCCC intern to use my testimonial in any format for future public relations purposes. This includes personal use by my intern(s) during their time in the SCCC or in their future practice.

I consent to the disclosure of my testimonial on various social media platforms, including, but not limited to Facebook, Instagram, Twitter(X), and any future entities involved in public relations for either SCCC or my SCCC intern. I understand that my testimonial may be utilized by the Sherman College Chiropractic Center and its interns to educate others, promote chiropractic care, and share real patient experiences.

My SCCC intern will not provide and/or release any of my protected health information to any social media or the public in any format, including private health information in my records, whereas the confidentiality is protected by state and federal statutes and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).

As this release is between my SCCC intern and myself, I waive the right of prior approval and hereby release Sherman College Chiropractic Center from any and all claims for damage of any kind based on the use of my testimonial or information contained in the testimonial.

By signing this form, you are hereby consenting to allow the Sherman College Chiropractic Center and your SCCC intern to use and disclose the information in your testimonial and acknowledge your testimonial may be distributed to the public.
You have the right to revoke this release at any time. If you wish to do so, you will need to contact your SCCC intern directly as Sherman College Chiropractic Center will not have the right to revoke the release.