Testimonial Consent Form

Testimonial and Feedback Consent Form

Patient's Information:

First Name

Last Name

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Purpose:

AVCRI - The Arya Vaidya Chikitsalayam and Research Institute seek your permission to collect, use, and share your feedback and testimonials regarding the treatment and care you received at our clinic. Your testimonials may be utilized in video, audio, or written formats for promotional and educational purposes across various platforms.

Use of Testimonials:

By providing your consent, you authorize AVCRI - The Arya Vaidya Chikitsalayam and Research Institute to:

Record your testimonials in video, audio, or written formats.
Use your testimonials on our social media, printed materials, multimedia presentations, and any other promotional platforms.
Edit the content for clarity and brevity, without misrepresenting your experience.
Include your name and likeness, unless anonymity is requested.

Consent Terms:

Participation is voluntary
You may withdraw your consent at any time by contacting us directly. Withdrawal will not affect materials already published or produced

Authorization:

I, , have read and understand the terms and conditions outlined in this consent form. I agree to the collection and use of my testimonials as described above.

Select date

For any concerns, Kindly contact

Patient Signature

Vaidya Dr. Jishnu, BAMS

The Arya Vaidya Chikitsalayam and Research Institute [AVCRI]
136,137, Trichy Road, Ramanathapuram,

Coimbatore, Tamilnadu - 641045

📧doctors@avtayurveda.com

Witness Name

Witness Signature

We're humbled by your continued belief in our vision.

Outpatient Appointments: 📞+91 422 2367238 | +91 422 2367220