Testimonial Form

We would love to have your chiropactic success story included for others to see and gain inspiration from! Please fill out the following form along with your story and a picture of yourself if you desire! Video testimonials are also welcome.

Thank you,
Kremer Chiropractic Clinic

I,__________________, do hereby give my authorization to Kremer Chiropractic Clinic and/or its representatives for the use of my photo and/or testimonial on their internet website. I understand that my photo will be used in publication for the purpose of information and/or advertising. I understand that there has not been, nor will there be, any financial arrangements or settlements promised to me for this, but that I freely volunteer my photo and testimonial. I agree to give only factual information. At any time I am free to contact Kremer Chiropractic Clinic and/or its representatives if I wish my testimonial and/or photos to be removed. I understand that Kremer Chiropractic Clinic and/or its representatives will do everything they can in a timely matter to attend to my request.

Print Name_________________________    Date_______________

Signature___________________________   Date_______________

Parent/Guardian______________________   Date_______________