Permission to Share
By submitting this form, I voluntarily provide the information contained in my story to The Oak Clinic and authorize The Oak Clinic to review and contact me regarding its potential use in patient stories, educational materials, fundraising and development communications, the Clinic's website, social media, newsletters, printed materials, and other Clinic communications.
I understand that sharing my story is completely voluntary and that choosing whether or not to participate will not affect my care, treatment, services, benefits, or relationship with The Oak Clinic.
I understand that my story may contain information about my health, diagnosis, treatment, or experiences receiving care. I understand that health information shared publicly may no longer be protected by federal or state privacy laws once it has been disclosed to the public.
The Oak Clinic will follow the name preference I selected above when sharing my story. I understand that even when my name is not published, details contained in my story could potentially allow someone who knows me to recognize me.
I understand that submitting a story does not guarantee that The Oak Clinic will publish or otherwise use it and that a member of The Oak Clinic team may contact me before publication to confirm details, obtain additional permissions, or complete any required authorization or release.
By selecting the acknowledgment below and submitting this form, I confirm that I have read and understand the information above and that I am voluntarily submitting my story.