Health Source - Chiropractic and Progressive Rehab

SECOND PRIZE WINNERS

To receive your second prize, FREE leather weekend tote bag ($49 value), please take a minute to fill out the brief survey below, and hit the “submit” tab at the end. This helps us serve our great profession, and we’ll send the bag out immediately. Again, thanks for stopping by the HealthSource Chiropractic booth, the fastest growing chiropractic franchise in the world.

All fields are required.

Doctor's Name:

Clinic Name:

Street Address:

Office Home

City:

State:

Zip:

Phone:

FAX:

Email:

Home Phone:

Cell Phone:

Number of Offices:

Years in Practice:

Gross Practice Revenues:
2005:
2006:
2007:
Net Pre-Tax Personal Income (Salary, Bonuses, Value of Benefits Paid for by Practice)
2007:
Personal Wealth & Financial Security
	Own Home
	Own Additional Real Estate
	Own Office Building
	Funding Pension Plans
	100% Under 100%
	In past 3 years, wealth has:
Practice Assessments (Rank EACH Item 1 - 10, 1 being of little importance, 10 being of great importance)
	Need for new patients
	Need for more predictable, consistent new patient flow
	Frustration with insurance and managed care
	Need for better office systems
	Need for more net income
	Need for better patient treatment systems
	Need for more patients per day
	Need for good employee training systems
	Need for help in selecting a great office manager
	Need for help with insurance coding
	Need for better collections systems
	Need for better chiropractic techniques
	Need for proven therapy protocols
	Need for advice and training relative to new modalities (decompression, cold laser)
	Need for help with selecting and training the perfect associate
	Need for help in learning how to open and run multiple clinics
	Need for help in determing your exit strategy
	Need for help in learning how to get "off the tables" and manage your business
	Need for proven, reliable marketing
	Need for being able to take vacations
	Need for a proven software system that allows you to manage from out of state
	Need for help with clinic location and lease negotiation
	Need for help with selecting a therapy protocol to compliment chiropractic
	Need for help with managing employees
Interests & Goals (Check all that apply)
	Increase Income
	Increase Value of Practice
	Increase Personal Wealth
	End Stress & Worry Over New Patients, Finances, Future
	See Patients Less
	Stop Seeing Patients Altogether Within years
	Exit Strategies - to retire in years
	Interested in owning multiple clinics
	Possibly interested in a Master Area Franchise to control an entire area
	More free time, more time with family
	Other:

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"On my first visit I rated my pain level a 25 (out of a possible 10). I couldn't sit, stand, walk, or lie down - no matter what position I tried, I was never without pain. I was taking 800 mg of Advil every 4 hours and sometimes more often. I was unable to do what I enjoy most, walking outside in the flower beds and cutting grass. Now, I feel absolutely terrific. I have become pain free in two and a half weeks. This is a very caring facility with a compassionate staff and they make you feel comfortable from the onset of treatment."

Mary Ann Hodapp, RN
Brunswick, Ohio