Patient Stories — HealthUnlocked

Share your story by answering a quick question

We are on a mission to share real-life experiences of what it's like to live with a health condition

What condition do you have? How has it impacted your mental health?

We understand that sharing your story via video can feel a little intimidating, which is we want to show you the question you’ll be answering before you get started.

What we’ll ask you

Patient Stories - Videos

I give my consent for HealthUnlocked, and its employees and sister company, the Patient Experience Team of CorEvitas, LLC, and its employees (“CorEvitas”) permission to use, publish, display, incorporate, reproduce, edit, or share in any form of media the following: My original recording, quote, or other original material, my image(s), or video/audio recordings that I submit to or are collected by CorEvitas (“Submission”). I grant CorEvitas permission to fully disclose my health status or conditions as described in the Submission. I grant CorEvitas permission to use my full name and the city/state/country of my residence to be published, broadcast, or otherwise displayed alongside the Submission. I understand CorEvitas will not share my contact information with third parties. I agree that CorEvitas shall maintain the rights to any resulting works, video, and/or audio recordings that CorEvitas creates based on, or incorporating, my Submission. CorEvitas may use my Submission for any purpose in part or in whole. I hereby release CorEvitas from any claims or causes of action, including but not limited to: libel, slander, invasion of the right of privacy, publicity, or personality, relating to CorEvitas’ use of my Submission. I attest that I am authorized to grant consent for CorEvitas’ use of the Submission. I certify that I am at least eighteen (18) years of age and of full legal capacity to grant this authorization. By clicking 'I consent' you are accepting all of the above.

I consent

Name

First Name

Last Name

Email

How it works:

Review our informed consent
Record your answer to our question
Submit your video answers and wait to hear from us about sharing your story

Patient Stories Consent Form

I give my consent for HealthUnlocked, and its employees and sister company, the Patient Experience Team of CorEvitas, LLC, and its employees (“CorEvitas”) permission to use, publish, display, incorporate, reproduce, edit, or share in any form of media the following: My original recording, quote, or other original material, my image(s), or video/audio recordings that I submit to or are collected by CorEvitas (“Submission”). I grant CorEvitas permission to fully disclose my health status or conditions as described in the Submission. I grant CorEvitas permission to use my full name and the city/state/country of my residence to be published, broadcast, or otherwise displayed alongside the Submission. I understand CorEvitas will not share my contact information with third parties. I agree that CorEvitas shall maintain the rights to any resulting works, video, and/or audio recordings that CorEvitas creates based on, or incorporating, my Submission. CorEvitas may use my Submission for any purpose in part or in whole. I hereby release CorEvitas from any claims or causes of action, including but not limited to: libel, slander, invasion of the right of privacy, publicity, or personality, relating to CorEvitas’ use of my Submission. I attest that I am authorized to grant consent for CorEvitas’ use of the Submission. I certify that I am at least eighteen (18) years of age and of full legal capacity to grant this authorization. By clicking 'I consent' you are accepting all of the above.

I consent

Name

First Name

Last Name

Email

Where we’ll show your story

We want to use your story to reach as many people as we can, so we can highlight the importance of peer-to-peer support to those who are going through similar health experiences as you.

We plan to share your video in the following places:

The Recording Process

1

Click 'Get Started' to review our informed consent form.

2

Record your answer

3

Wait to hear back from us before we share your story