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Practice intake
Please fill out this form to help us gain some insight before our discovery call.
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Name
*
Your answer
Email
*
Your answer
Business Name
*
Your answer
Years in business?
*
Your answer
City:
*
Your answer
Type of practice:
*
Clinic
Mobile
Home office
Other:
Required
Number of practitioners:
*
Your answer
Booking system used
*
Massage Book
Jane App
Other:
Types of direct billing services
*
Massage Therapy
Physio Therapy
Acupuncture
Chiropractor
Other:
Required
Days of the week the practice is open:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Required
Average number of appointments per day:
*
Your answer
Does your current intake form collect insurance information for direct billing?
*
Yes
No
How do you currently do direct billing and payments? Do you offer direct billing, collect payment via credit card, cash, etc.
*
Your answer
Any other details you would like to add
Your answer
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