Dandelion Nutrition Client Testimonial Release Authorization Form
With your permission, I would like to use your comments as a testimonial to help inform potential clients how they can benefit from working with me. To help you get started, I’ve included a few questions, but please feel free to write whatever you like.

-- What prompted you to seek nutrition counseling from me?
-- How did you benefit from working with me? What were your results?
-- What exactly did I do that was helpful for you?
-- If a potential client was on the fence about whether to work with me or not, what would you say to them?

Email address
Overall, how was your experience with Marlene Maltby, RDN?
Please provide your testimonial and/or review here:
Tell prospective clients about your experience working with Marlene Maltby, RDN.
Your answer
I permit to be identified in the following way(s) for my client testimonial (select all that apply):
Purpose of Authorization:
By signing this authorization form, I am authorizing Dandelion Nutrition to distribute and share my client testimonial that I provided. Sharing my client testimonial may include posting the information on the company website, posting the testimonial information on the company’s social media pages, and including my testimonial on printed advertisements and promotions. I agree that I am voluntarily sharing my testimonial about services from Dandelion Nutrition, and I am receiving no financial remuneration from Dandelion Nutrition for providing my testimonial and allowing the company to use my protected health information for marketing purposes.
Right to Revoke:
I understand that I have the right to revoke this authorization at any time by providing a written request to Dandelion Nutrition. I understand that if I choose to revoke this authorization, it will become effective on the day of the revocation of the authorization. Any prior uses and disclosures of my testimonial with my protected health information will not be subject to the revocation of the authorization. I understand that Dandelion Nutrition will make it best effort to remove my testimonial and protected health information from the Dandelion Nutrition website and other social media pages.
Components of my Testimonial:
I understand that the client testimonial for Dandelion Nutrition will only include my name, location, photograph, and information provided to the organization in my testimonial. I understand that all other protected health information that Dandelion Nutrition creates and maintains for purposes of my care will not be used in my testimonial or for marketing purposes without prior authorization per privacy regulations of the state and Health Insurance Portability and Accountability Act (HIPAA).
Electronic Signature
Please type your First and Last Name
Your answer
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