Doctor's Name (will not appear in testimonial)

Doctor's Email Address (will not appear in testimonial)

Health problem of patient prior to chiropractic care.

Patient's full name 
(please include full name, however, only first name will appear in testimonial)

If you are including a scan of the patient picture, please email it as an attachment to the following email address: picture@chiropractictestimonials.com Please make sure you include the patient name and doctor name with the email.

Patient's Town or City

Patient's State, Province or Country (country if outside USA)

Patient testimonial below.  Type or paste the patient testimonial in the space below.

Special instructions or additional comments from the doctor.

THE FOLLOWING MUST BE SELECTED BY THE DOCTOR
I certify that the testimonial submitted is true.  I have kept a copy of the original patient testimonial which is available for review.  I also have obtained specific permission from the patient to use this testimonial on this web site.
I certify the above by selecting:   Yes    No

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