The form below is to provide a testimonial and/or photographs regarding your experience working with Mr Hiroshi Nishikawa; he and the team are very pleased you are happy to share your story.

By submitting a testimonial and photos to us you agree that we may publish your testimonial, together with your name and town you live in, on our website and on any successor websites that we may operate from time to time, on such page and in such position as we may determine in our sole discretion.

You further agree that we may edit the testimonial and publish edited or partial versions of the testimonial on our partner website (The Westbourne Centre) and through our social media channels.  Please rest assured, we will never edit a testimonial in such a way as to create a misleading impression of your views.

Title *

Procedure *

Please select the type of procedure, if this not applicable please leave blank. Selected procedure will appear in left column.

Date of Procedure

Please select the date of your procedure, if this not applicable please leave blank.

Overall Rating (out of 5) *

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Testimonial

Please use the field below to write your testimonial.

Short summary

Please give a short summary of your testimonial (160 Characters).

Images

Please upload any images that you are happy to go along side your testimonial

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Your details

Public displayed name * When publishing testimonials, our standard format for names is first name, last initial, town (i.e. Michelle D., Sutton Coldfield) and also an optional profile image. Location (Town) * Profile photo Idealy a head shot photo, although this is optional Name * Please let us know your name for our records, this won't be published to the public. E-mail Address * Please let us know your email for our records, this won't be published to the public. Phone Number * Please let us know your phone number for our records, this won't be published to the public.

Public displayed name * When publishing testimonials, our standard format for names is first name, last initial, town (i.e. Michelle D., Sutton Coldfield) and also an optional profile image. Location (Town) * Profile photo Idealy a head shot photo, although this is optional Name * Please let us know your name for our records, this won't be published to the public. E-mail Address * Please let us know your email for our records, this won't be published to the public. Phone Number * Please let us know your phone number for our records, this won't be published to the public.

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