1) Describe the condition(s) for which you reached out to Via Vitae Chiropractic. Please explain the name of the condition and symptoms you have experienced: *

b) How long have you had this condition(s)? *

c) How did this condition prevent you from living everyday life? *

2) Were you ever treated by any other doctors, such as an orthopedist, neurologist, and/ or physical therapist for this problem? If yes, what kind of doctor treated you and what were the results? *

3) How did you find Via Vitae Chiropractic? *

4) What drugs and/or medications and/or lifestyle changes were you able to reduce or eliminate (if any) after getting under care? *

5) Did you have any doubts in the beginning that chiropractic would help you? *

6) What were your first impressions of Via Vitae Chiropractic and your doctor? *

7) Please describe your results, including how long it took to achieve these results *

8) Please describe how your life has changed now that you are under upper cervical care and have seen improvements in your health *

9) Would you recommend Via Vitae Chiropractic to others and why? *

10) Please add any additional comments about your experience that you would like to share with others

For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Via Vitae Chiropractic, or anyone authorized by Via Vitae Chiropractic, of any and all photographs/videos/testimonials and names which have been taken of me on this day. They will be used for the purpose of promotional TV, marketing, and/or print ads whatsoever without further compensation to me. All negatives and positives, together with the prints, shall constitute the property of Via Vitae Chiropractic solely and completely. Via Vitae Chiropractic reserves the right to make any grammatical changes to the testimonial stories for marketing use. Any information voluntarily provided shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentiality, in regards to any reported conditions, is also waived to the extent of information pertinent to the promotional material only. All other unrelated patient information shall remain private and protected (according to Health Information and Privacy Act laws).

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