Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Would you be willing to share your experience with the public? *

Yes

No

How can we use your story? *

In Draw the Curtain materials, including social media content, on our website, and emails.

In external media, such as TV, radio and newspapers, including their websites and social media channels

Would you like personal details to be used within your story or remain anonymous? *

I am happy for my personal details to be used as part of my story

I would like to remain anonymous

Consent *

I understand that the information I provide here may be shared publicly by the Oklahoma State Medical Association, and I hereby give my consent for its use in any format, including but not limited to digital, print, and video formats. My consent extends to my personal information, including my name and the health information I’ve provided here. I verify that the information I have provided pertains to me and only to me, and that it is true to the best of my knowledge.

I agree

I do not agree

Would you be interested in receiving updates from the Draw the Curtain campaign?

Yes

No