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Application:
Step 1
About You & Your Practice
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About You
First Name
*
Last Name
*
Email
*
Office Phone
*
Mobile Phone
DC License State
*
International (Non-U.S./Canada)
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Labrador
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
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New Mexico
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North Carolina
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Ohio
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Ontario
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Puerto Rico
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon Territory
DC License Number
*
DC License Date
*
MM slash DD slash YYYY
Pre-Chiropractic College
*
Doctor of Chiropractic Degree Received From
Chiropractic Graduation Year
*
Your Office
Practice / Office / Company Name
Office Street Address
Office City
*
Office State
*
Office Postal/Zip Code
*
How many exam / adjusting / patient areas are in your office?
*
What Technique(s) do you Practice?
*
Do You Have X-Rays on Site?
*
Yes
No
Do You Read Your Own X-Rays?
*
Yes
No
Sometimes
Do You Refer to DACBR?
*
Yes
No
Sometimes
How often do you refer to DACBR?
*
Do you refer patients for lab evaluations?
*
Yes
No
How often do you refer patients for lab evaluations?
*
Do you use physical therapy modalities?
*
Yes
No
Average Number of Patients Seen Daily?
*
Percentage Acute:
*
Percentage Chronic:
*
Percentage Wellness:
*
Malpractice Insurance Carrier
*
Preceptor Doctors
Next Steps & Application Status
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DC Applicant
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