Signup Form Main ContactContact Name First Last Contact TitleContact Email Contact PhoneDo you have a website? I don't have a website yet Mailchimp subscribe Please add me to the ChiroBrite mailing list Practice DetailsPractice NamePractice Website Practice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Practice PhoneAdditional ContactsListNameTitleEmailPhone Service PlanYou will be charged the startup fee at this time for the service plan that you chose. The monthly fee will not begin until your website launches.Select Your Service Plan*MinisiteStarterStandardPremiumMinisite Startup Fee Price: $399.00 Starter Startup Fee Price: $499.00 Standard Startup Fee Price: $599.00 Premium Startup Fee Price: $999.00 *PLEASE NOTE* The premium plan is subject to approval as it is dedicated and reserved for elite practices and is limited in number of sites per geographic jurisdiction. Please fill out the additional information below to determine if you are eligible for acceptance as a premium client.Premium Plan ApplicationMain Patient Drawing Area(This is the city/town/etc. where most of your patients come from - typically the same as your office location)Additional Patient Drawing AreasMany times a practice will draw patients from surrounding communities. Please list any additional areas that you draw patients from. Techniques Diversified Gonstead Thompson Activator Upper Cervical Other Other Techniques List any other techniques you utilizeWhat makes you an elite Chiropractor / Chiropractic Office?Why should we select your practice as a premium client?Site Add-onsSelect Your Add-ons E-Commerce – $69.99 ($19.99/mo)Add the ability to sell products on your site. Event Calendar – $19.99 ($9.99/mo)Easily publish and manage events on your website. Logo Design – $399.99A professional, unique, one-of-a-kind logo created specifically for your practice. Social Media Integration – $69.99Extend your visual brand into your social channels - Facebook, Twitter, Instagram, Google +, YouTube. Copywriting – $399.99Professional copywriting services for compelling website copy. (6-10 pages) Content Marketing – $299.99 ($399/mo)Content Marketing services such as blog creation, social posts, content creation and marketing. Photography – $TBDProfessional photography for your staff and office. Headshots, team photos, candid office photos, etc. Location map – $49.99Custom designed map to match your site and help visitors find your office easily. E-Commerce Price: $69.99 Add the ability to sell products on your site. (Monthly Fee - $19.99)Event Calendar Price: $19.99 Easily publish and manage events on your website. (Monthly Fee - $9.99)Logo Design Price: $399.99 A professional, unique, one-of-a-kind logo created specifically for your practice.Social Media Integration Price: $69.99 Extend your visual brand into your social channels - Facebook, Twitter, Instagram, Google +, YouTube.Copywriting Price: $399.99 Professional copywriting services for compelling website copy. (6-10 pages)Content Marketing Price: $299.99 Content Marketing services such as blog creation, social posts, content creation and marketing. Photography Price: $0.00 Professional photography for your staff and office. Headshots, team photos, candid office photos, etc. Location Map Price: $49.99 Custom designed map to match your site and help visitors find your office easily.PaymentTotal $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Δ