Add your patient story

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.

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

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

    Please use the field below to write your testimonial.

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

    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.

    Idealy a head shot photo, although this is optional

    Please let us know your name for our records, this won't be published to the public.

    Please let us know your email for our records, this won't be published to the public.

    Please let us know your phone number for our records, this won't be published to the public.

    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.

    Idealy a head shot photo, although this is optional

    Please let us know your name for our records, this won't be published to the public.

    Please let us know your email for our records, this won't be published to the public.

    Please let us know your phone number for our records, this won't be published to the public.