Testimonial Submission – SHAPE ReClaimed

Patient/Client Information
Your Name*
First NAME Last INITIAL
Your Email*
Age*
Gender*
Length of time on the SHAPE Program*
Top 3 improvements from SHAPE Program*
Symptoms improved/eliminated, conditions improved/resolved, medications reduced/eliminated, pounds/inches shed, etc.
Patient/Client Testimonial Quote*
How would you describe your experience?
Additional Notes
Transformation Photo (1)
Accepted file types: jpg, jpeg, png, gif.
Transformation Photo (2)
Accepted file types: jpg, jpeg, png, gif.
Transformation Photo (3)
Accepted file types: jpg, jpeg, png, gif.
Transformation Photo (4)
Accepted file types: jpg, jpeg, png, gif.
Video
Max. file size: 256 MB.
Practitioner Information
Name*
First Name Last Name
Consent form*
I agree.
By checking this box and submitting this form, I agree that SHAPE ReClaimed, LLC may use my testimony, photos and/or video for any lawful purpose for illustration and website content. I further agree that my first name and last initial may be revealed in descriptive text or commentary in connection with the image (s). I authorize the use of these images without compensation to me. I agree these photo (s) reflect my transformation accurately and have not been altered or enhanced.

Patient/Client Information