MPTA Patient Testimonial Submission Question Title * 1. Please provide your contact information~ Therapist Name Practice/Facility Name City/Town Email Address Phone Number OK Question Title * 2. Age of patient OK Question Title * 3. Reason for treatment (Injury/Condition) - Please do not include protected health information OK Question Title * 4. Description of patient's function pre and post treatment OK Question Title * 5. Which would be best to convey this patient's story? Video Print Social Media OK Question Title * 6. Would this patient be engaging on video? Yes No OK Question Title * 7. Is this patient's story or personality better suited for print media? Yes No Comments and/or additional information: OK SUBMIT