UK Sepsis Trust - Testimonial Consent Form
The United Kingdom Sepsis Trust produces a range of communications to demonstrate the work we do and to raise awareness of sepsis. Allowing us to share your stories helps us to continue raising awareness.
By completing this form, you give us permission to use your story in our communications.
You can state below if you are happy for us to use your real name, or if you prefer to remain anonymous. The consent form is valid for 3 years - if we want to continue to use your story after this time, we will contact you again. But in the meantime, you can always contact us if you change your mind in the meantime, and we will stop using your story.
Thank you for your help.
First name
Last name
Email address
Phone number
First line of your address
Town or city
Postcode
Your story
What is your experience of sepsis?
Sepsis survivor
Bereaved by sepsis
Someone I know had sepsis
Healthcare professional
Which support services from UKST does this testimonial relate to?
Helpline
Face 2 Face support group
Online Support & Connect group
Facebook group
Edu-therapy
Resources
Tell your story or share your testimonial about the UK Sepsis Trust here:
What can the story be used for?
Presentations - for external and internal use
Website and social media (including Facebook, Instagram, LinkedIn, X, TikTok and YouTube)
Publications (leaflets, posters, newsletters)
Television and radio
Share with 3rd parties (external organisations may ask for case study material to promote awareness and UKST through their social media channels)
Can I remain anonymous?
You can choose to have your real name published with your story or remain anonymous (where we use a false name).
I am happy for my/my relative's name to be used
I prefer to remain anonymous
Would you like to share any photos or documents to be used alongside your testimonial?
Yes
No
Please upload any photos or documents here
I am happy for any images I have supplied to the UK Sepsis Trust to be used for the purposes above and confirm I own the rights to these images
Yes