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ChiroSpring
ULTIMATE PACKAGE
Please fill out the form below. We will use the information from this form to prepare the actual Service Agreement. We will then send you the actual service agreement and credit card processing form.
Customer Information
Business Address
Billing Address
Billing same as business
ChiroSpring Billing Service
Yes - This saves me time
Yes - I would like more information
No - I am not interested
Provide two email addresses ChiroSpring will use to send you information.
Do you need existing patients imported into ChiroSpring?
No - I do not need patients imported into ChiroSpring
Yes - I need patients imported into ChiroSpring
List All Users You Would Like Added to ChiroSpring.
Prefix*
Mr.
Mrs.
Ms.
Dr.
Prof.
Type*
General User
Chiropractor
Acupuncturist
Massage Therapist
Physical Therapist Medical Doctor
Physical Therapist Nurse Practitioner
Nurse
Referral Program (Who were you referred by?)
By existing ChiroSpring customer
Additional Information
How Did You Hear About Us? *
Web Search
Web Advertisement
Email Invitation
Phone Invitation
Customer Referral
Other Referral
Capterra
ChiroMonkey
Facebook
Linkedin
Google Plus
YouTube
Web Chat
Colleague
Palmer Event
Chiropractic Economics Magazine
Practice Insights Magazine
The American Chiropractor Magazine
Palmer Insights Magazine
The Beacon
National University Event
Logan Event
Other Advertsiement
Trade Show
Seminar
Other
Using ChiroSpring with a Mac, PC or Both?
Mac
PC
Both