My Chiropractic Story Testimonial Submission

  • We will include a photo of you if desired with your story. (you can email us a favorite photo of you to or we can take your picture here in our office!) Thank you for helping us tell others about how chiropractic can help them have a stronger, healthier spine for life!
  • Tell us about your health struggles before you started care:

  • Now tell us how chiropractic helped you:

  • For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Revelation Chiropractic, or anyone authorized by Revelation Chiropractic, of any and all photographs/videos/documents which you have this day taken of me, for the purpose of promotional TV/social media/print/ads, videos, etc., without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Revelation Chiropractic, solely and completely. Any information voluntarily provided by a patient shall also be used in conjunction with the above-listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also waived to the extent of information pertinent to the promotion material only. All other unrelated patient information shall remain private and protected (according to Health Information and Privacy Act laws.)