* Indicates a required value..
Email *
First Name *
Last Name *
Address 1
Address 2
City
State
ZIP
Home Phone
FAX Phone
Work Phone
Social Security Number
Date of Birth
Place of Birth
Spouse's First Name
Spouse's Last Name
* Have you practiced before? Yes No
(If Yes, Where?)
* How long and why you left?
* How did you hear of Practice Starters ©?
* Who referred you to Practice Starters ©?
* What is the name of your chiropractic college?
* Number of years attended:
* Date Graduated
* Date Will Graduate
* What activities did you participate in, and what honors did you receive during chiropractic college
* In what states are you licensed?
* What state are you interested in practicing in?
* When are you taking boards?
* For which states?
* What chiropractic technique(s) do you utilize?
* What size town do you want to practice in (population)?
* Any specific town?
* What equipment do you own?
* What type of professional equipment would you like to start practice with?
* Physiotherapy-list preferences
* Do you have financing approval by any bank or leasing company for your office equipment (in writing)?
Yes No
* How much money do you have available to open your practice?
* What are your present debts-amounts owed and to whom?
* In what portions of starting a practice do you feel you need help?
CHOOSING TOWN
CHOOSING LOCATION
FLOOR PLANS
CONSTRUCTION RECOMMENDATIONS
SIGN DESIGN
BUILDING LEASE EVALUATION
EQUIPMENT LEASING
FINANCES
STAFF SELECTION AND TRAINING
ADVERTISING
INSURANCE PROCEDURES
Other
* Do you desire an associateship with an established D.C. before starting your own private practice?
Yes No
* If you are accepted into Practice Starters© Program, what assistance do you expect?
* What type of services do you see yourself offering?
* What is your first month's income goal?
$
* Third month income goal?
$
* First year income goal?
$
If you are married, please have your spouse answer the questions below. If you are single, click submit.
Name:

How Long Married?
What Are Your What Are Your Spouse’s
Assets?
Weaknesses?
Desires?
What can Practice Starters© do to help you?
What can Practice Starters© do to help your spouse?
Are you willing to assist your spouse to go the extra mile in practice?
Do You Have Any Restrictions on Your Spouse’s Time?
Yes No
(If Yes, What?)


 FREE Practice Starters Guide   |  Home  |  Practice Starters® Program  |  Private Client  |  FREE Phone Consultation  |  Online Video Seminars  |  Two Free Videos  |  Weekend Seminars  |  How to Buy & Sell a Practice  |  Marketing/ Advertising/ Public Relations  |  Equipment, Forms and Supplies  |  Free Newsletter  |  Contact Us