Fitness Plus Inc. - Chiropractor In Valley City; ND; USA

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Initial Practice Questionnaire

Please complete this profile and we will contact your office to schedule this complimentary review and consultation. (This and ALL future communication 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? *

Would you like to learn how to create, customize and introduce dynamic health, wellness and fitness programs to your patient's?

Do you want to offer cash based programs in your practice?

How valuable would it be if someone could help you create, expand and customize additional services and revenue streams that would focus on active care recommendations for your patient's?

What type of impact would it have to improve your patient education, treatment options and grow a cash based health, wellness and fitness program?

Monthly Practice Statistics

Office Visits

New Patients

Services

Collections

Total active care codes per/month

List your top three sources of new patient referrals:

MD/DOEmployersYellow PagesPatient ReferralsAdsAttorney ReferralsMulti ClinicWork ShopsInsurance PlansOther

Office Description

Type of Office:

Total sq. ft. of Clinic:

Total sq. ft. available for rehab:

Are you currently providing ANY active care/rehabilitation services:

What percentage of your patients receive therapy/modalities on each visit?

Are you currently using Range of Motion/Manual Muscle Testing Equipment?

Do you have a seperate passive bay in your practice?

Check the modalities you use:

UltrasoundHeatSeparate passive therapy bayEMSIntersegmental TractionInterferential

Do you own rehab exercise equipment?

If yes, please list:

Which equipment/products are you currently using?

Stability ballsWall mounted stationResistance tubingWobble/Rocker BoardTreadmills or stationary bikePlate loaded machine

Are you struggling to:

Attract new patientsIncrease patient retentionUnderstand proper documentationExpand revenue streamsRecommend rehab plans with confidence

How did you hear about us?

PublicationsSeminarE-MailMailerSurfing

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Verification Code: *

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