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Chiropractor Intake Form
This is all about you so let's get started!
33
Questions
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1
Business Name
That name that the public recognizes you by
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2
How long have you had you practice?
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3
How many locations do you have?
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4
How many doctors do you have?
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5
What is the average cost of a single session?
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6
Who pays for it? (client cash or insurance?) ex 50/50 - 70/30
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7
How many times do you typically see each client per month?
Per Year?
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8
How many times do you typically see each client per year?
Per Year?
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9
How many patients do you see per day?
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10
How many patients do you see per week?
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11
How many patients do you see per month?
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12
What is the lifetime value of a client? ?
At what point do they fall off?
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13
Are you selling these people anything else? Ancillary services or products?
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14
Do you have an in-house marketing person?
Yes
No
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15
What type of marketing are you doing?
Social Media
Conferences
Digital Ads
Video Content
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16
How often do your reach out each week/month?
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17
Who do you use for email marketing?
Mailchimp
Constant Contact
Woosender
Klayvio
Other
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18
How big is your email list?
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19
Do you have a CRM system?
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20
How do you deploy your social media?
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21
How do you deploy your social media?
Manually
Through a software (hootsuite)
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22
Who supports your website?
Self Serve
Hired Designer/Developer
The content was created for me
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23
When is the last time you updated your website?
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24
What booking system are you using?
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25
Do you ask for and make it easy for someone to leave an online review?
Yes
No
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26
Do you ask for feedback when the work is finished?
Yes
No
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27
Do you have a referral program?
Yes
No
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28
What's most important to you?
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29
Do you want more time or more money?
Time
Money
BOTH
Other
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30
How do you records your customer intake form?
Paper
Ipad
Email
Phone
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31
How much revenue do you bring in a month?
In usd
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32
How much do you spend each month in marketing?
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33
Are you open to adding a Sauna and or Cold plunge to your practice?
Yes
No
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