A Way of Life Acupuncture - Testimonial Form We love to hear what you have to say. Please take a moment and share a little about your experience at A Way of Life Acupuncture. By taking the time to fill out this brief form, you may be helping someone you do not know decide to try acupuncture. What a wonderful way to contribute to the health and healing of the world, one person at a time. Please feel free to use additional space provided. Thank you for your feedback. Question Title * 1. What were the conditions that brought you to seek care at A Way of Life Acupuncture? Question Title * 2. What have your improvements been and how have they contributed to the quality of your life? Question Title * 3. Would you feel comfortable referring friends and/or family members to A Way of Life Acupuncture? Question Title * 4. What is your overall level of satisfaction at A Way of Life Acupuncture? Question Title * 5. May we use your story to encourage other patients? Yes No Question Title * 6. Any other comments or suggestions? Question Title * 7. I hereby give Christine Yastrzemski, A Way of Life Acupuncture, the right and permission to reproduce, publish, circulate or otherwise use my full name and testimonial. I understand my testimonial may be edited for clarity and/or conciseness. I Agree Question Title * 8. Please type how you would like your name to appear under the testimonial. (i.e. C Yastrzemski, PVB, Christine Y, PVB) Done