Profit Boost Application

1
What is your name? (Ex: Dr. Smith)* This field is required.
2
Email* This field is required.This is the email we will contact if you're selected, so pick the email address that is easiest to reach you!
example@example.com
3
Phone Number* This field is required.This is the phone number we will contact if you're selected, so pick the number that is easiest to reach you!
Please enter a valid phone number.
4
Website* This field is required.Website URL
5
Are you a Lone Wolf or Team Player?* This field is required.Multi-Practitioner includes things like massage therapist, acupuncturist, physical therapist, etc.
Solo Chiropractor
Multi-Practitioner
6
What word best describes your practice?* This field is required.
Holistic/Wellness
Sports
Injury/Rehab
Family
Other
7
What's your revenue goal in the next 12 months?* This field is required.
8
What was your gross revenue over the past year?* This field is required.
9
Over the last 3 months, how many visits were on your schedule each week on average?* This field is required.
10
What's the largest number of visits you could handle each week?* This field is required.Assume all are regular adjustments.
11
Over the last 3 months, how many new patients have you averaged each month?* This field is required.
12
How many new patients do you want each month?* This field is required.
13
Over the last 12 months, how many new patients have you averaged each month?* This field is required.
1 - 5 New Patients
6 - 10 New Patients
11 - 15 New Patients
16 - 20 New Patients
21+ New Patients
14
Are you a cash or insurance based practice?* This field is required.
Cash
Insurance
Even Split
15
How much do you charge per visit?* This field is required.
16
Do you Offer Care Plans?* This field is required.
Yes
No
17
On average, how much do you charge for your care plan?* This field is required.
18
On average, how many appointments do you recommend for a care plan?* This field is required.Give your best guess if you don't know!
19
On average, how many appointments in the care plan are completed?* This field is required.
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
20
How Do People Pay for the Care Plan? (Give the Approximate Percentage Split)* This field is required.Give your best guess if you don't know!
Pay Up Front
Payment Plan
Pay-Per-Visit
Don't Purchase Care Plan
Percentages
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Percentages
Pay Up Front
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Payment Plan
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Pay-Per-Visit
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Don't Purchase Care Plan
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21
On average what’s the PVA of your patients? (average number of visits a patient comes in for across the lifetime of them being a patient)* This field is required.Give your best guess if you don't know! P.S. After you press submit, don't forget to fill in your contact info on the next page so we know where to send your results!
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