| Name:_______________________________________ | Age:___________ |
Address:_____________________________________ |
Yrs. In Practice:________ |
| ____________________________________________ | Solo Practice:_____ |
| ____________________________________________ | Partnership:_____ |
Phone:_____________________Fax_______________ |
Associate:_____ |
| E -mail address:___________________________________________________ | |
| Technique(s) :__________________________________________________________ | |
| Therapies:_____________________________________________________________ | |
| X-Ray: All Patients:____ Acute Patients:____ Other:________________________ | |
| Participate w/Insurances: Y____ N____ Cash Practice: Y____ N____ | |
| Website:______________________________________ | |
| Do You: Public Speak_____ Write Articles_____ Radio/TV_____ | |
Do You Currently: Belong to a Practice Management Group: Y____ N____ If so, which one:_______________________________________ Belong to a National Organization: Y____ N____ If so, which one:_______________________________________ Prescribe Orthotics: Y____ N____ If so, is it with Foot Levelers, or ___________________________ Prescribe Rehab Programs: Y____ N____ Prescribe Nutritional Supplements: Y____ N____ |
|
Charge $300.00 now, and again on the 15th
of each Month:_____ Charge full with 10% discount $1,620.00):_______ |
|
CC#:________________________________________ |
Date of Exp.____________ |
| Signature:_____________________________________________________ |