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The Mobile Practice Application Form
1
Name
First Name
Last Name
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2
Current Business Name ("Other" if Not a Practice Owner)
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3
E-mail
example@example.com
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4
Phone Number
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5
Do you currently provide mobile services? If yes, what are you hoping to get from this program?
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6
When do you plan to launch your mobile practice?
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7
What is your current #1 concern about launching a mobile practice?
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8
If accepted, do you or a team member have at least 10 hours/week to commit to launching?
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9
Are you coachable and open to implementing feedback?
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10
If we both agree this program is a good fit to help you build a successful and profitable practice, when will you be ready to invest in working with me to help you reach your goals?
Please Select
A Few Months From Now
In the Next Couple of Weeks
Yesterday
I'm Not Sure
I'm Not Ready to Invest in Guidance For This Initiative
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Please Select
A Few Months From Now
In the Next Couple of Weeks
Yesterday
I'm Not Sure
I'm Not Ready to Invest in Guidance For This Initiative
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