Share your military story!

Contact information

Name(Required)

Mailing Address(Required)

Phone Number(Required)

Email Address(Required)

Questionnaire

What is your current military status?(Required)

Active Duty

Retired

Veteran

National Guard or Reserves

In which branch of military did you serve?(Required)

During which years were you / have you been active?

Start Date(Required)

End Date *If currently active, enter today's date.(Required)

What was or has your experience been like?(Required)

Please share any funny or inspiring stories you have about your service.(Required)

What are the most important things your military service taught you? Did it improve your character?(Required)

What advice would you give someone thinking of serving in the military?(Required)

Please add a few photos to accompany your story. (A pic of you while in service in uniform should be included.)(Required)

Drop files here or

Max. file size: 50 MB.

AIM4VETS Authorization and Release of Testimonial Information

I understand that my testimonial, as outlined above (the "Testimonial") and made on behalf of Atlanta Innovative Medicine, LLC (hereinafter called "The Practice"), may be used in connection with publicizing and promoting The Practice.

I authorize The Practice to use my name, brief biographical information, photo and the Testimonial as defined on this form. I hereby irrevocably authorize The Practice to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Practice’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media.

I agree that I will make no monetary or other claim against The Practice for the use of the statement. In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears. I hereby hold harmless and release The Practice from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Printed Name:(Required)

Digital Signature:(Required)