First Name (Required)

Last Name (Required)

Email (Required)

Phone

City

Province/State

Your Success Story (required)

Please confirm that we have your permission to print and share your success story in our newsletters, website, advertising or elsewhere to encourage others to enjoy the benefits of hypnosis.
YesNo

If you answer no, your testimonial may appear on the Romane website only.

Please confirm that we may post, publicize, or advertise your hypnosis experience with Romane with your first name, last name, city, and photo. Please choose all that apply:
First name onlyFirst name and initialFull first and last nameJust initialsCity and ProvincePhoto

(Optional) - Upload a picture of yourself to go with your testimonial: (JPG or GIF only)