Share your story · Patient voices
There is no one-size-fits-all thyroid treatment. Tell us what worked for you.
Patient stories are the most powerful evidence we have. Record a short video (60 to 90 seconds) about your thyroid journey and the medicine that finally worked for you, read and sign the consent and release below, then upload your video to our secure Dropbox page. Our team reviews every submission before anything is shared.
How it works
Four steps, about ten minutes.
1
Record your video
2
Read the release
3
Sign, then upload
4
We review
Consent & release
Please read this before you sign.
Part 1 · Consent and Release for Use of Story, Video, Name, and Likeness
By completing and submitting the form on this page, I (the “Participant”) voluntarily give The Thyroid Foundation, a 501(c)(3) nonprofit organization, Charleston Thyroid Center, LLC, and MyThyroidDoctor (together, the “Organizations”) permission to use the video I upload to the Organizations’ Dropbox file request, together with my name (as I have chosen below), likeness, voice, and the story I tell, in the ways I have selected on the form. Those uses may include educational and professional presentations and conferences, social media accounts operated by the Organizations (including @mythyroiddoctor), the Organizations’ websites, newsletters, and printed or digital patient-education and advocacy materials.
I grant the Organizations a non-exclusive, royalty-free, worldwide license to record, copy, edit, caption, shorten, reproduce, publish, display, distribute, and otherwise use my video and story, in whole or in part, in any media now known or later developed, for the uses I have selected. I understand that my video may be edited for length or clarity, that I will not be paid for this use, and that I waive any right to inspect or approve the finished material or the context in which it appears. I retain ownership of my video and may continue to share it myself.
I confirm that I am at least 18 years old, that the video is my own and shows only me (or that I have permission from any other person who appears), and that what I say in it is true to my own experience. I understand that my story describes my personal experience and is not medical advice for anyone else.
I may withdraw this consent at any time by emailing thethyroidfoundation@gmail.com. The Organizations will stop new uses of my video within a reasonable time after receiving my request and will make reasonable efforts to remove it from channels they control, but I understand that material already published, printed, presented, or shared by others may not be fully retrievable.
Part 2 · HIPAA Authorization for Use and Disclosure of Protected Health Information
Who may disclose: Charleston Thyroid Center, LLC and MyThyroidDoctor (the “Practices”), if I am or have been their patient, and me.
What may be disclosed: my name, image, voice, and the health information I choose to share in my video and on the form, which may include my thyroid diagnosis, symptoms, test results I mention, and the treatments and medications I have used.
Who may receive it: The Thyroid Foundation, Charleston Thyroid Center, LLC, MyThyroidDoctor, and the public and audiences reached through the uses I have selected on the form.
Purpose: at my request, for patient education, awareness, and advocacy about individualized thyroid care.
Expiration: this authorization remains in effect until I revoke it in writing. Right to revoke: I may revoke this authorization at any time by emailing thethyroidfoundation@gmail.com, except to the extent the Practices or Organizations have already acted in reliance on it. Redisclosure: I understand that once my information is shared publicly it may no longer be protected by federal privacy law (HIPAA) and may be re-shared by others. No conditions: my treatment, payment, enrollment, or eligibility for benefits will not be affected by whether or not I sign this authorization. Copy: I will receive a copy of this authorization by email when I submit the form.
Part 3 · Important things to know before you submit
Every video is reviewed first. Your signed release is emailed to our team, and your video goes to a private Dropbox folder that only our team can see; videos are never stored on this website. Both are reviewed together. Nothing is posted or presented automatically. Submitting a video does not guarantee it will be used. Some videos will not be used, and we may trim or caption those we do use. We will not use your video in any way you have not selected on the form.
Keep it personal, not promotional. Please describe your own experience and the medicine that worked for you. We cannot use videos that name other patients, make claims about other people’s results, or promote a specific pharmacy or product for sale.
This is a public story. If you choose first name only or no name, we will not add your name, but you may still be recognizable from your face and voice. Think about what you are comfortable sharing before you record.
Your contact details stay private. Your email, phone number, and date of birth are used only to verify your identity, keep a record of your consent, and contact you about your submission. They are never published.
The form
Sign the release and upload your video.
Fields marked with an asterisk are required. Your contact details are never published.