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Main Contact

Contact Name

First Last

Contact Title

Contact Email

Contact Phone

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Practice Details

Practice Name

Practice Website

Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice Phone

Additional Contacts

List

Name	Title	Email	Phone

Service Plan

You 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*

Minisite
Starter
Standard
Premium

Minisite 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 Application

Main 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 Areas

Many 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 utilize

What makes you an elite Chiropractor / Chiropractic Office?

Why should we select your practice as a premium client?

Site Add-ons

Select 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 – $399.99
A professional, unique, one-of-a-kind logo created specifically for your practice.
Social Media Integration – $69.99
Extend your visual brand into your social channels - Facebook, Twitter, Instagram, Google +, YouTube.
Copywriting – $399.99
Professional 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 – $TBD
Professional photography for your staff and office. Headshots, team photos, candid office photos, etc.
Location map – $49.99
Custom 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.

Payment

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name