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                        ( Required fields marked * )

Personal
Information

FIRST NAME: * LAST NAME: *

CA / OFFICE MGR NAME: *   *

PRACTICE NAME: *

ADDRESS:
* CITY: *

STATE: * ZIP: *

PHONE: *    FAX: *

CELL: *    EMAIL ADDRESS: *

SS#:

OWNERSHIP:

STATE LICENSED IN: LICENSE#:

How long have you owned the Insight Subluxation Station?:   Month(s)

PAYMENT METHOD:

HAVE YOU EVER   YES                           NO

FILED BANKRUPTCY *

HAD BOARD ACTION AGAINST YOU *

BEEN A DEFENDANT IN ANY LEGAL ACTIONS *

HAD A LOAN FORCECLOSED *

Practice Information

WEEKLY PATIENT VOLUME: * PATIENT VISIT AVERAGE (PVA):

AVERAGE MONTHLY NEW PATIENTS:

GROSS MONTHLY COLLECTIONS: $           OVERHEAD PERCENTAGE: %

LIST PERCENTAGE OF REIMBURSEMENT: PL:       %                   WORK COMP: % GENERAL INS: %

CASH: %                   MEDICARE:     % HMO:                 %

SQUARE FOOTAGE OF: OFFICE:       RECEPTION AREA:

DESCRIBE YOUR PRACTICE: (Family, PL, etc.)

DO YOU CURRENTLY SELL PRODUCTS: YES   NO PERCENTAGE OF YOU INCOME: %

IF YES PLEASE LIST: (Be specific)