I request consideration to attend Discovery Day to learn more about ownership of a HealthSource Chiropractic franchise(s). I understand that, in the Closed Door Briefing that I will attend, certain proprietary information, trade secrets, copyrighted marketing materials, confidential financial data and similar information will be disclosed, and I warrant that I will treat all such disclosures as privileged and confidential. In attending the Closed Door Briefing, I am evaluating the opportunity, and being evaluated, and incur no financial obligation by doing so. If I elect to leave at end of the Discovery Day and not secure a franchise(s), I will turn in all materials and notes.

    I agree [must be checked to attend]

Please complete and submit the form below to receive your Uniform Offering Circular detailing the HealthSource franchise opportunity.
All fields are required.

Dr. Name:
Practice Name:
Practice Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Years in Practice
Check One:	Single Office Multi-Office
Check One:	Solo Practitioner Have  Associate Doctor(s)
	Have you ever been sanctioned, fined, or suspended by a state chiropractic board, sanctioned, fined, prosecuted by any other regulatory agency, convicted of a misdemeanor or felony, or sued civilly?
Check One:	Yes No
	If Yes, please describe:
Desired Date:	Check here for upcoming dates
Form Security Code:
Enter Security Code:

Your decision to attend the HealthSource Discovery Day is only to look at, examine, and be looked at with respect to a HealthSource franchise. It is not a decision to join HealthSource at this time. Only after attending the Discovery Day will you have all the information with which to make an informed decision.

You will receive a Uniform Offering Circular detailing the HealthSource franchise opportunity 3 days from today, via Fed-Ex.