Doctor Intake Form
Chiropractor
Full Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prefix
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Website URL (if applicable)
example@example.com
How did you hear about us?
*
Please Select
Social Media
Internet
Referral
Other
How Many Years In Practice
Please Select
Less Than 1 Year
1-3 Years
4-10 Years
10+ Years
What Are Your Chiropractic Specialties?
General Chiropractic Care
Sports Injury & Rehabilitation
Pediatric Chiropractic
Prenatal Chiropractic
Posture & Ergonomic Correction
Pain Management
Other
Do You Currently Have A Team?
Solo Practioner
Small Team (1-3 Staff)
Medium Team (4-10 Staff)
Large Team (11+ Staff)
What Are Your Top Three Goals For The Next 6 Months?
What's The Biggest Challenge Preventing You From Achieving These Goals?
Not Enough New Patients
Low Patient Retention/Rebooking
Weak Online Presence Or Low Website Traffic
Ineffective Social Media Marketing
Poor Lead Follow-Up System
Other
Do You Currently Use Social Media For Your Practice?
Facebook
Instagram
TikTok
YouTube
LinkedIn
I Don't Use Social Media
How Often Do You Post On Social Media
Daily
2-3 Times A Week
Once A Week
Rarely/Never
Do You Currently Run Paid Social Media Ads
Yes, Currently Running Ads
I've Tried But Didn't See Results
No, But I'm Interested
No, I prefer Organic Marketing
How Do You Currently Generate New Patients?
Word-Of-Mouth Referrals
Google Search & Website Traffic
Local Community Events Or Networking
Partnerships With Other Businesses (Gyms, PT's, Wellness Centers, Injury Attorneys)
What Type Of Marketing Support Do You Need? (Check All That Apply)
Website Optimization & SEO Improvement
Social Media Management & Content
Facebook & Instagram Advertising
Google Ads & Local SEO Strategy
Lead Generation & Patient Conversion Strategies
Email Marketing & Patient Follow-Up Automation
What Is Your Estimated Marketing Budget Per Month
Under $500
$500-$1,500
$1,500-$3,000
$3,000+
Are You Open To Creating Videos Or Sharing Photos For Marketing Purposes?
Yes, I Can Provide Videos/Photos
I Need Help Creating Content
I Prefer Text-Based Content Only
Do You Have A System In Place To Follow Up With Potential Patients?
Yes, We Follow Up Via Phone, Email, Or Text
No, I Need A Better Follow-Up System
I'm Not Sure
How Will You Define Success In This Partnership? (Check All That Apply)
More New Patient Appointments
Higher Patient Retention & Repeat Visits
Increased Online Engagement & Brand Awareness
Higher Revenue & Profitability
Improved Website & Ad Performance
How Soon Are You Looking To Get Started
Immediately
In The Next 30 Days
In The Next 3-6 Months
Submit
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