Name *
Birth Date *
Birth Date
Contact *
May we contact you to clarify points of your story?
Describe what conditions caused you to look into Henze Chiropractic & Wellness
What had you tried before coming in to Henze Chiropractic & Wellness? What was the result?
How did your treatment(s) at Henze Chiropractic & Wellness improve your condition(s)?
How long did it take to see results?
How are you doing now?
Publishing Permission - Web *
Do we have your permission to publish your story on our website?
Publishing Permission - ChiroTV *
Do we have your permission to make a slideshow to display on the monitors inside our clinic?