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Let's Get Started!
We're going to ask some basic questions about your practice over the next few pages, many of which are simple yes/no answers. First, let's make sure we have all your contact information correct.
Name
*
First
Last
Clinic Name
Office Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Office Phone
*
Fax
Mobile Phone
*
Email
*
Date of Birth
*
Month
Day
Year
How did you hear about us?
*
If you heard about us from another doctor, please let us know their name.
Fantastic!
Next we're going to ask a little about your chiropractic background.
Chiropractic Background
Tell us a little more about yourself and your training.
What school did you graduate from?
*
What year did you graduate?
*
Have you recently thought about getting out of chiropractic?
*
Yes
No
Why have you thought about getting out of chiropractic?
Have you ever been with a chiropractic management course or instruction?
*
Yes
No
Which management courses or instruction have you taken?
This doesn't need to be a complete list. Just tell us the highlights you think are important.
Great Progress!
You're doing great! Next we're going to ask a bit about your facilities and location.
Facilities and Location
Tell us how your office and location are set up.
What is the approximate square footage of your practice?
*
Do you share common office facilities with any other Chiropractor or Professional?
*
Yes
No
Do you have more than one office location?
*
Yes
No
Awesome! Keep at it!
Next we need to see where your office is financially. Don't worry, this is only to help us understand your practice and will be kept in strictest confidence.
Financial Information for the past three months
If you need to look up this information and come back later you can always use the "Save and Continue Later" button at the bottom of this page. If you do, we'll send you an email link you can use to pick up right where you left off when you return. This is the biggest section, but it's crucial that we know how your business is doing to best understand how to help.
Financial Information for last month
This is the last full month you have information on. These numbers don't need to be to the penny, but more accurate information will help us better understand your practice.
What was your total monthly overhead/expenses last month?
*
What was your total in services last month?
*
What was your total in collections last month?
*
How many patient visits did you have last month?
*
How many new patients did you have last month?
*
Financial Information for two months ago
What was your total monthly overhead/expenses two months ago?
*
What was your total in services two months ago?
*
What was your total in collections two months ago?
*
How many patient visits did you have two months ago?
*
How many new patients did you have two months ago?
*
Financial Information for three months ago
What was your total monthly overhead/expenses three months ago?
*
What was your total in services three months ago?
*
What was your total in collections three months ago?
*
How many patient visits did you have three months ago?
*
How many new patients did you have three months ago?
*
Whew, you made it!
There's just one last question about your financials.
Do you perform other ancillary services, such as: nutrition, orthotics, massage, etc.?
*
Yes
No
Moving on
Next, let's do a quick head count in your office.
Office/Clerical Staff
How many full time staff members do you have?
*
How many part time staff members do you have?
*
Almost done!
To wrap up, we're going to ask a few final questions about your practice.
Your Practice
These questions help us determine if there are any areas we should help you focus on.
Do you currently operate a cash practice?
*
Yes
No
Are you currently having issues with third-party payers?
*
Yes
No
What diagnostic equipment do you have?
*
What interests you the most?
*
Pain based practice? (Personal Injury)
Wellness care based practice?
Traditional subluxation based practice? (Chiropractic only)
What are your motivating factors for applying to be part of the program? (check all that apply)
Learn to work smarter not harder (i.e. more efficient to reduce workload)
New patient acquisition via marketing and/or referral programs
Increase net revenue
Increase patient compliance/retention to overall recommendations (improving patient communication and perceived value)
What percentage of your practice is made up by:
Chiropractic Percentage (%)
Please enter a number from
0
to
100
.
Nutrition Percentage (%)
Please enter a number from
0
to
100
.
Functional Therapies Percentage (%)
Please enter a number from
0
to
100
.
Other Percentage (%)
Please enter a number from
0
to
100
.
Which of those are you most interested in increasing it’s value in your practice?
*
Chiropractic
Nutrition
Functional Therapies
Other
If nutrition/functional medicine plays a part in your practice what kind of monthly inventory expense or capital equipment expenditure has that added to your overhead?
Would you be willing to participate by reporting statistics, attending Boot Camps, visiting training centers, and opening your office for evaluation?
*
Yes
No
Success!
Hit that submit button below to package up your answers and send them off to us!
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