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Chiropractic Marketing Success Coaching Program Application

Just fill out this simple application, and before you know it, we'll be working together to get you more patients than ever before, while making as much profit for you as possible.     Within 24-48 hours of submitting this application, either myself or my office manager will call you and discuss your needs and the best way for you to reach your goals.  If it looks like we can work together, I'll send you the full registration form that has questions designed to help me help you, and we'll setup your coaching schedule for the next few months.     So right now, fill out this application, and in as little as one day, you can start operating at peak performance, and make more profits than you had previously thought possible!

Name:

Title:

Clinic Name:

Address:

City, State, ZIP:

Phone:

Fax:

E-Mail Address:

Web Site Address:

Visa

MasterCard

Payment Method:

American Express

Discover

Credit Card #:

Exp. Date:

Payment In Full ($12,936)

Twelve Monthly Payments of $1,192 (Total $14,304)

Average # of Patient Visits Per Week:

1-50 51-100 101-200 201-500 501-1,000 1,001+

Years In Practice:

Average # of New Patients Per Week:

1-2 3-5 6-10 11-25 26-50 51+

Patient Retention

What Would You Like To Improve In Your Practice? (Check all that apply)

New Patients

Collections/Billing

Other

Where Did You Hear About Us:

Comments or Suggestions:

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