Submit a Testimonial

Please tell us your story by filling out the following form. We truly appreciate your feedback.

* Indicates a Required Field.

Upload a Photo of Yourself:

(Acceptable Formats: JPEG, GIF, PNG)

Please Review Our Legal Agreement

I hereby authorize my testimonial to be used for testimonial advertisement in Shane R. Hanzlik, MD, PC’s promotional material, including Shane R. Hanzlik, MD, PC’s website, brochures, and advertisements. I waive the right of prior approval and hereby release and discharge Shane R. Hanzlik, MD, PC and all persons acting under the permission and authority of Shane R. Hanzlik, MD, PC from liability, damages, compensation or actions of any kind based on the use of my testimonial or information in the testimonial.

By signing below, I agree and acknowledge that I have read and understood the above Release and agree to all terms described. I am of legal age and freely sign this consent to release my patient testimonial.

(Typing your name here indicates that all of the above information is accurate and acts as your electronic signature.)