Sign-up – Patients' Mirror

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Last Name *

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(123)123-4563 *

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Patient Disclosure Statement

Thank you for considering participation in our documentary project. To ensure confidentiality and comply with privacy regulations, please adhere to the following guidelines when expressing interest in our project:

What to Provide: Please provide only your name and phone number at this stage. Avoid sharing any details about your medical condition or personal information.
Initial Contact: Upon receiving your contact information, we will arrange an initial phone interview. This conversation will help us understand your interest and determine the suitability of proceeding further.
Consent Process: If we mutually agree to move forward after the initial interview, you will be required to complete a patient information consent release form. This form is crucial for protecting your privacy and rights during the documentary process.
Comprehensive Interview: Following the consent, a detailed online interview will be conducted. This interview aims to assess the feasibility of developing a documentary centered on your experiences living with a chronic condition, capturing the highs, lows, and aspirations of your journey.
Information Retention: If at any stage you/we decide not to move forward, all your contact information will be removed from our databases to ensure your privacy.

By providing your name and phone number, you agree to this initial process, under which no further personal or medical information should be disclosed until the appropriate consent forms are completed.

Thank you for your interest and cooperation.

Patient Disclosure Statement

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