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Initial Practice Survey
Please complete this profile and we will contact your office to schedule
this complimentary review and consultation.  (This and ALL future
communications will be kept completely confidential.)
Office Information
Practice Name:
Name:
Address:
City:
State:
Zip code:
Phone:
Fax:
Home Phone:
E-Mail:
Best Time to Contact:
Chiropractic College:
What year did you graduate?
Are you satisfied with the current status of your practice?            Yes     No
Would you like to learn how to create, customize and introduce dynamic health, wellness and fitness programs to your patient's?             Yes     No
Do you want to offer cash based programs in your practice?
Yes     No
How valuable would it be if someone could help you create expand and customize additional services and revenure streams that would focus on active care, health and wellness recommendations for your patient's ?

Very     Somewhat     Not at all
What type of impact would it have to improve your patient education, treatment options and grow a cash based health, wellness, fitness and human performance program?

Very     Somewhat     Not at all
Practice Demographics
Monthly Practice Statistics:
Office Visits
New Patient's
Services
Collections
Total active care codes per/month
List your top three sources of new patient referrals:
MD/DOAttorney Referrals
EmployersMulti Clinic
Yellow PagesWork Shops
Patient ReferralsInsurance Plans
Ads
Other:
Office Description & Operations
Type of Office:
Office BuildingStore Front
Home OfficeHigh Rise
Other:
Total sq. ft. of clinic:
Total sq. ft. available for rehab:
Are you currently providing  ANY active care/rehabilitation services:Yes     No
What percentage of your patients receives therapy/modalities on each visit? %
Are you currently using Range of Motion/Manual Muscle Testing Equipment?      Yes     No
Do you have a separate passive bay in your practice?
Check the modalities you use:
UltrasoundEMS
HeatIntersegmental Traction
Separate passive therapy bayInterferential
Do you own rehab exercise equipment:     Yes     No
If yes, please list:
Which equipment/products are you currently using?
Stability BallsWobble/Rocker Board
Wall mounted stationTreadmills or stationary bike
Resistance tubingPlate loaded machine
Are you struggling to:
Attract new patientsExpand revenue streams
Increase patient retentionRecommend rehab plans with confidence
Understand proper documentation
How did you hear about us?
Did you find us on a Search Engine? GoogleYahooMSN
WE MAKE REHAB & WELLNESS EASY... ONE STEP AT A TIME
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