Welcome Back Spinal Care Centre - Treatment Request Form

Testimonial Form
It is important for us at Welcome Back to share the experience of those who have benefited from our care with patients who have never experienced our treatment. A comment about your experience can help others understand what we do. Please share any information you would deem helpful. Some examples are your condition, how long you had it, how many treatments you received, how the treatment helped, how long it has been since you’ve had your condition after treatment. Please feel free to write as much or as little as you’d like. Please understand that your statement may be used in website or print advertising or marketing for Welcome Back Spinal Care Centre.

Submission of this form indicates your consent as above.

Thank you for your assistance.

Name

Email

Address City

Please indicate if we can use your

Full Name (eg. John Smith)

First Name and Last Initial (eg. John S.)

City Name

Profession

Your profession (if checked)

May we use your

Photo (headshot)

Would you be willing to do a

video testimonial

EITHER send us a file with your comments here (eg. doc, docx, pdf)

OR, please enter your comments here

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