ChiroVision... Changing the world, one practice at a time.
ChiroVision... Changing the world, one practice at a time. ChiroVision... Changing the world, one practice at a time. ChiroVision... Changing the world, one practice at a time. ChiroVision... Changing the world, one practice at a time. ChiroVision... Changing the world, one practice at a time.

Contact Information

Please take a moment to tell us a little about your practice and needs by filling out the form below. You can contact ChiroVision by calling at 1-800 GET WELL (1-800 438-9355). in the U.S. or 516-791-5008 outside the U.S. To send an e-mail, address it to ChiroVision@aol.com.

Please fill out the entire form for an accurate evaluation. If you do not feel comfortable filling out everything, please note that required fields are marked with °
Your Name ° Your E-mail Address °
Your Phone Number ° What is the best time to contact you?
What is the name of your practice? Street Address
City State
Zip / Postal Code Country
About Your Practice
During the slowest weeks of practice, about how many patients do you adjust? During the busiest weeks of practice, about how many patients do you adjust?
How Many Patients would you like to adjust each week?
Please list the tools you currently use in educating your patients.

Feel Free to list any pamphlets, posters, models, videos and software you use.		 How would you describe your outside office promotion? Non-existent
Needs Help
Minimal but satisfactory
Proactive
How do you manage your patients?(check all that apply) Ortho exams    Chiropractic exams    X-ray analysis    Functional testing
How many minutes does your report of findings usually last? How often do you give your patients a progress report? Every Visits 
Out of 100%, what grade would you give your present staff as far as professionalism and effectiveness? How many minutes do your progress reports usually last?
Out of 100%, what grade would you give yourself as far as professionalism and effectiveness? Please select a time frame in which you would like to see better results occur.
© 2007 ChiroVision