Skip to content Submit Your Story Submit Your Story Leave this field blank First Name Last Name Phone Email Gender MaleFemalePrefer not to say Date of Birth View additional details about the consent form here. I certify that I am 18 years of age or older I authorize that Digital Medicine contact me regarding the use of my patient story. By checking this box, I authorize Digital Medicine to utilize my story Tell us about your story of care. Stories are reviewed by our team for consideration to be shared in short articles and/or videos, so feel free to include details about who you are — your hobbies, passions, and/or community involvement activities. Your Story Upload Image to Story I have a video to submit with my story. We will contact you on the steps of retrieving the video. Electronic Signature Date Contact Information For Person Submitting Form (if other than patient) First Name Last Name Email Phone I am the parent or authorized guardian of the aforementioned patient Submit This form does not encrypt your message and it is not an appropriate means of communicating confidential information. Do not use this form to send personal information, such as account numbers, insurance information or social security numbers. We do not provide medical advice through this form.