Surgical Weight Loss Testimonial

By electronically signing this form, I grant Iowa Weight Loss Specialists and Iowa Specialty Hospital and their employee’s permission to use my photo, filmed image and/or personal testimonial taken on the date indicated below for publicity, educational purposes, website and/or social media (including, but not limited to, Facebook, Twitter and YouTube).

I understand that I will not be paid or receive any reimbursement for the use of my photo, filmed image and /or testimonial. I further give Iowa Weight Loss Specialists and Iowa Specialty Hospital and their employee’s permission to use my name and/or information that was given in accordance with my photo, filmed image and/or testimonial.