Improvement Report

We love when our clients share their success stories with us so we can share them with others as a source of encouragement and hope. Thank you for sharing your story of improvement and healing with us!

Name *

First

Last

Email *

Confirm Email

Why did you come to the Well of Life? Was it particular symptoms? Was there a health issue you were having that was not being addressed properly? *

How are you feeling now since you have started coming to the Well of Life Center? *

Additional Comments:

Video Testimonial

We have an opportunity for you to earn $15 instead of $10 off! We invite you to come to our office and have one of our staff members video tape your testimony of improvement in addition to your written report. We would be thrilled to capture your testimony on tape and share it with others! If you are interested, a member of our team will be in touch with you to schedule your taping. (Testimony only needs to be a few minutes in length - no specific format required.)

Choose one: *

I am interested in scheduling a video testimony and earning $15 off instead of $10
I am NOT interested in scheduling a video testimony at this time

Authorization for Use: *

I do hereby give the Well of Life Center for Natural Health, LLC, their assigns, licenses, and legal representatives the irrevocable right to use my name (or any fictional name), picture, portrait, video, videotaped recording, or photograph in all forms and media in all manners, including composite or distorted representations, for advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith. I am of full age. I have read this release and am fully familiar with its contents.

I authorize the Well of Life Center to utilize my success/improvement report in the following manner: *

Success story book that remains in our offices at all times.
Success story on our website and/or Facebook page (your last name will not be used).
Any promotional mailing by the Well of Life to help make its services broadly known.

Today's Date: *

Signature: *

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Improvement Report

Video Testimonial

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