WEB: Success Stories Consent To Release Information

Select which applies:*

I am a clinicianI am a patientI am a family member/caregiver
Patient Name*

First NameLast Name
Parent/Guardian/Caregiver/Clinician Name (If Applicable)

First NameLast Name
Title (If Applicable)
Facility Name (If Applicable)
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
Rehab Facility Attended
Clinician Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I give to Restorative Therapies, Inc., it's employees, physicians, volunteers and others officially working on behalf of Restorative Therapies, Inc. permission and consent for (Select all that are allowed):*

An interview or quote(s)Photograph(s)Video(s)
For purposes of publication in/on (Check all that are allowed):*

All Internal and External Media UseTraining MaterialsRestorative Therapies' WebsiteNewspapers, Magazines, All Print and Digital MediaAll Social Media (Facebook, X, LinkedIn, Instagram, Google+, TikTok, etc.)
Do you participate in social media?
What are your handles? (Tag us on Instagram/Twitter/TikTok: @rticonnect FB/LinkedIn: @restothera)
I relieve and agree not to hold Restorative Therapies, Inc. liable for the interviewing and photographing, and subsequent publication or broadcasting. I understand that the interviews and photographs are being carried out with my consent and I assume responsibility for my consent.

Any questions about this consent form may be directed to:

Restorative Therapies, Inc.
8098 Sandpiper Circle, Suite M, Nottingham, MD 21236
Phone: 800-609-9166
Email: marketing@restorative-therapies.com
Date*

MonthDayYear
Date
Patient Signature
Permissions

Please check one of the following if applicable and complete the section below:
I am a parent/guardian completing this form on behalf of a patient 18 yrs of age or younger.I am a caregiver and have permission to complete this form on behalf of a patientI am a clinician and have permission to complete this form on behalf of a patient
Parent/Guardian/Caregiver/Clinician Name

First NameLast Name
Parent/Guardian/Caregiver/Clinician Signature
Please provide a short quote on the benefits you have experienced from using the RT300 as part of your therapy program. (Type 'N/A' is not applicable)*
Please provide a short quote on the benefits you have experienced from using the Xcite2 Therapy System (Type 'N/A' is not applicable)*
Please provide a brief summary of your life BEFORE your injury hobbies, interests, career, etc. *
Please provide a brief summary of how your life has been impacted AFTER your injury hobbies, interests, career, etc. *
How has the RT300 and/or Xcite2 Therapy Systems helped you in your journey to recovery? *
Please upload 3-5 images or videos of you using the RT300 and/or Xcite2!*

Cancelof
Should be Empty:

Permissions