Tell us about your health struggles before you started care:

Please leave this field empty.

What conditions and symptoms were you struggling with before starting care?

How long had you been dealing with it? (days, weeks, months, years?)

Were you ever treated by any doctors such as an orthopedist, neurologist, and/or physical therapist for this problem? If yes, who treated you and what were your results?

Tell what drugs or medications you were taking for this. have you been able to reduce or eliminate them since starting chiropractic care?

Did you have doubts that chiropractic would help you? Explain.

Now tell us how chiropractic helped you:

What were your first impressions of chiropractic, this office, and Dr. Chad?

What improvements have you noticed in how your body is healing and functioning since starting care? Do you think your body is stronger/healthier/functions better now? How?

Would you recommend chiropractic to others who are sick, suffering, or in pain?

Please add any additional comments about your experience and/or benefits at our office you would like others to know about.

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.)

Consent*

I have read and agree to the terms listed above.

Name*

First Name

Last Name

Email*

CAPTCHA