Start by checking one or both of the boxes below to indicate how you would like to share.
We love to hear how our rapid recovery treatment has positively impacted the lives of our patients. Submit a testimonial and your story could be featured on our blog and/or social media channels.
Photo Wall
Our providers love to share photos of their happy patients on their office walls. Choose this option to grant your provider permission to display your photo on his or her patient photo wall.
Then fill out and submit the form below. (fields marked are required to submit)
Photo (Optional)
Attach a photo of you doing an activity you love doing.(Photo must be under 4MB)
When you click Submit you will be asked to read and accept an "Authorization for Use or Disclosure of Health Information" form. You must be at least 18 years of age to accept the terms of this document electronically. If you are under the age of 18, please contact to obtain the appropriate form. A copy of the electronically signed agreement will be sent to the email address you provide above; please retain this copy for your records.
For questions or concerns please call (800) 404-6050
I hereby voluntarily authorize Airrosti Rehab Centers, LLC and its subsidiaries and affiliates (“Airrosti”) to use and disclose my health information (such as my name, demographic information, social media addresses, videos, audio recordings, photographs, and testimonials, statements, and comments about my care and health condition) (collectively “Information”) as described below.
Description: I authorize the disclosure of my Information in oral, written or electronic form to the public, including via social media websites (such as Facebook or Twitter, etc.), and/or other websites including the Airrosti website, via physical postings of photographs and autographed items on the Airrosti office walls or bulletin boards, and by Airrosti in general (“Authorized Recipients”). I authorize Airrosti to obtain my Information from me, its internal records or from any public sources, websites, social media postings or re-postings.
Purpose: The Information is being released for the purpose of Airrosti marketing its services. If such Information is de-identified, I authorize Airrosti to re-identify my Information for this purpose.
Expiration: This Authorization will expire on the date when Airrosti is no longer in the business of providing healthcare services.
Acknowledgements: I understand that I may refuse to sign this Authorization, and that my health care treatment will not be conditioned upon signing this form. I also understand that my Information is subject to re-disclosure by the Authorized Recipients and that, once released, the Information may no longer be protected by federal privacy regulations. I also understand that I may revoke this Authorization at any time by notifying Airrosti in writing, but if I do, the revocation will not have any effect on any actions Airrosti took before receipt of my revocation of this Authorization.
I acknowledge that I: (i) am 18 years of age or older and have the right to contract in my own name; (ii) have read and understand the contents of this Authorization; (iii) agree and consent to this Authorization by electronic means; and (iv) hereby state that electronic signatures shall have the same force and effect as original signatures with respect to these terms and all written agreements and understandings entered into between Airrosti and myself.
Click “I Accept” to acknowledge that you have read and agree to the terms of the Authorization for Use or Disclosure of Health Information document. If you do not agree, you may leave this window by closing it, or navigating to another window, and your testimonial and/or photo will not be used.
For questions or concerns please call (800) 404-6050
Thank you!
Your information has been submitted. You should recieve your copy of the Authorization for Use or Disclosure of Health Information document though email shortly; please retain this copy for your records. You may close this window, or click the link below to learn more about Airrosti.
Go to the Airrosti homepage
For questions or concerns please call (800) 404-6050