Platinum Package Application

You are one step closer to your new patient explosion!

Please fill out the following application and we will be in contact with you within 12 hours if we are able accept you as a client.


Your Contact Information

Name (required)

Email (required)

Telephone (required)

Address (required)

City (required)

State/Province (required)

Zip/Postal (required)

Country (required)

 


What are your current practice statistics?

Avg. Patient Visits/Week

Total Active Patients

Avg. New Patients/Month

 

What percentage of your practice is based on cash? Insurance?

Cash:

Insurance:

 

Which practice management, coaching or consulting company have you been a member or are currently a member of?

Name?

How long?

 

Please describe how you recommend care to your patients? For example, do you prescribe detailed care plans or recommend your care visit by visit. Please explain your processes thoroughly.

Do you train yourself regularly on practice procedures? For example, training on specifics for patient communication. If so, what types of things do you train on and how often?

Do you consistently train your staff? If so, what do you train on and how often do you meet with your staff training?


What are your goals for practice? What would you like your MINIMAL annual income to be? How many active patients would you like to be seeing every week?

Describe what your dream practice would look like?

NOTE: Be sure to check your junk mail for your confirmation if you don't receive it within an hour.

 

WARNING: You will receive an email from customer service asking you to opt-in to receive further communication from us.  This must be done in order to proceed through your setup.  If you do not receive this notification within 15 minutes then please contact us here.

© 2019: 3S Systems Inc.

back to top