Share Your Success Story With Us....

Use the form below to tell us how our information and / or products helped you to get rid of your back pain and get your life back. The more specifics and details the better.

Important Message: Please do not ask for help or request customer support from this form, as the results of this page are only viewed monthly. For customer service help visit the contact us page, and click on "Email Customer Service" and your request will be resolved.
1. Your Contact Information
2. Your Condition & Relief Journey
3. Your Personal Story

Supported formats: MOV, MPEG4, MP4, AVI, WMV, WebM, JPG, JPEG, PNG, MP3 (Max file size: 25MB).

Healthy Back Institute

Customer Testimonial Release Consent

Purpose of Consent:

By signing this form, you are hereby consenting to allow SW Management Group, LLC dba The Healthy Back Institute to use and disclose the information you provided in your video / photo / written / or audio customer testimonial and acknowledge that your testimonial may be viewed / read by the public.

Consent to Release:

I hereby authorize and allow SW Management Group, LLC dba The Healthy Back Institute and staff to use my testimonial and any information contained herein in its public relations efforts.

I waive the right of prior approval and hereby release SW Management Group, LLC dba The Healthy Back Institute from any and all claims for damages of any kind based on the use of my testimonial or information provided within the testimonial.

By clicking 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 customer Testimonial.

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The Healthy Back Institute • www.LoseTheBackPain.com