Send Us Your Video Testimonial

Did you have an exceptional experience at our office working with Dr. Josh Bross, Dr. John Terrier, Dr. Carson Aune, or one of our other staff members? Have we helped you regain pain free living, reclaim your mobility, or improve your sports performance and you’re excited to tell us about it?

Send us a video review! Video reviews let us know we’re doing a good job, build our community in Columbia, MD, and let other patients know what to expect. When we can hear from you personally, we can continue to grow and improve. Send us a video review below, we’d love to hear from you.

Name

Message

Video

PHI Use and Disclosure Authorization

Authorization to Use and Disclose Protected Health Information
I, The Patient, authorize Elite Chiropractic & Sport, to use and disclose my video testimonial for marketing and promotional purposes. I understand that this may include, but is not limited to, publication on the practice's website, social media pages, promotional materials, and other forms of media.

I understand that information that is disclosed under this authorization may be disclosed by the recipient as such the privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to. I understand that my authorization is not required as a condition to receive treatment, payment, or enrollment or eligibility for benefits.

I understand that I have the right to terminate or revoke this authorization at any time. To do so, my request must be provided to your office in writing. Written requests can be emailed to info@elitechirosport.com.

Date

Sign Below to Allow Use of Video Testimonial

How to Send Us a Video Review

1) Record yourself on your phone or camera giving us a personal review of your experience working with us. Try to answer the following questions in your recording:

How did you hear about us?
How did we differ from other offices you have been to?
How long did it take to feel better?
What can you do now you couldn’t do before?
What makes Elite different from everyone else?
Would you refer other patients to us?

2) Use the form on this page to upload your video

3) Agree to allow us to use your video on our website or social media (click and sign)

4) Send the form! It’s that easy

Tips for Recording Your Video Review

Record in a well lit area where we can clearly see your face – in front of a window or in your car (not driving) are all great places
Avoid background noise that could interfere, like TV, music, or other people
Keep the video under 90 seconds (even though we know you could say so much more!)
Make sure you are the only person in your video

Why Didn't My Video Go Through?

Check the file is saved as .mov or .mp4
Resize the video file — we accept files up to 128mb
Did you confirm you are not a robot and include your name and email?
Please click the box next to “Authorization” to allow us to use the video on our web channels and include an e-signature (click and sign)

How Will My Video Be Used?

Elite Chiropractic and Sport will display select videos on our website and possibly on social media as part of a video review collection. No personal information will be shared aside from what you include in the video and your first name.

Our authorization disclosure includes details to the use of the media and allows you to revoke our use at any time if you send us an email.

I Want to Leave a Review But Not a Video - Can I Do That?

Absolutely! We also accept reviews and feedback on Google, Facebook, and other review pages. Click “leave us a review” below to send us a review on Google!