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Your success story may serve as inspiration and encouragement to others who are struggling with spine issues. Once complete, please email this form to.This is to certify that I have chosen to give my testimonial as a patient of Clarke EyeCare Center. Purpose of Consent: By signing this form (the "Release"), you are authorizing CareConnect. To fully protect you medical records in the hands of another person, you need to fill out a Patient Release Form. View our samples for this document now! Endodontic Patient Testimonial. By submitting this form, you are agreeing to allow us to publish your survey on our website and social media channels.