We would love to speak with you about your practice situation to see if our coaching program would be right for you. Please complete this brief evaluation and press the "submit" button. One of our staff will call you in the next 2 business days to schedule a complimentary 15 minute consultation with Dr. Madeira. Thank You.

     
 
Your Name

First Name

MI

Last Name
 
     
 
Marital Status
Married Divorced Widowed Separated Single
 
     
 
Address

City

State/
Province

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Contact Information

Office

Cell

Email

How did you here about us?

 Ad

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 Referred by friend: Name 
 
     
 
Practice Information

Chiropractic College

Years in Practice
 Type of Practice: Solo Group Multi-Discipline
 Are You: Owner Associate/Employee Partner

Primary Adjusting Technique(s)

Average number of office visits you see per week:

Average number of new patients you attract month:

Average collections per month:

Average time (in minutes) you spend with each patient:

How many staff do you have?

Is your staff "on fire and on purpose"?

What causes you most of your stress?

 
     
 
 Are you as passionate about chiropractic as you would like? Yes No
 Are you living the lifestyle you have always dreamed of? Yes No
 Do you take as much vacation as you would like? Yes No
 Are you spending as much quality time with your spouse/children as you would like? Yes No
 Is your practice as profitable as you would like? Yes No
 Is a lack of new patients, income, profitability balance or stress affecting the level of  joy in your life? Yes No

What three things do you most need our help with?

1.
2.
3.
 Do you currently have a coach? Yes No
 How interested are you in joining our coaching program?
not interested somewhat interested very interested I'm ready to join